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OPERATIVE DENTISTRY. 



PRACTICAL TREATISE 



ON 



OPERATIVE DENTISTRY. 



Bt J. TAFT, 



PROFESSOR OF (I BIO COLLI I 



WITH 



^ 






EIGHTY ILLUSTRATIONS. 



^COP 









PHILADELPHIA: 

LINDSAY & BLAKI8TON. 



4 



Entered, according to Act of CongreM, in the year 18M, 
BY UVMAT * l»I a 
In the Clerk's Office of the I *• !■*•»» W*rfct €f P*or 



»n 1 Cherry Stre*tt, 






i 4J 






PREFACE. 



The exigences of the Profession seemed to require, 
for the department of Operative Dentistry, a work that 
should contain all that La known in this branch of 
To answer that requirement, the author 
of the present work has aimed to furnish, in as (.im- 
pact a form a^ possible, the Principles of the Science, 
properly digested, the Experiments Detailed, the 

Manipnlatio: rilx d, and the whole methodized 

and thus made available to the Student and the 

Practitioner. In the accomplishment of this object, 

he has. he believes, included everything meritorious or 

important in this department of Dental Study. 

To the dental writers whose labors have lightened, 

in any degree, the toil of this undertaking, the Intelli- 
gent reader will ascribe the credit due; and to the 

meknbers of the profession, whose suggestions have 

found place iu various parts of the volume, the author 

gratefully acknowledges his obligations. 

J. TAFT, 

Cin< iw.vTi, July 1, 18* 



CONTENTS, 



CHAPTER I 



Introduction, 
Deposits, 

Tartar, . 

Origin of, 
Points of Dep< 
Effects of, 

Method uf Removing, 
Green Tartar, 
Origin of, . 

:ttllH/!lt of, . 

. 

Atrophy, 

B of, 

Exostosis, 

. 

Cause of, 
Denuding, 
Chemical Abrasion, 

Cause of, 
Necrosis of the Teeth, . 

Causes of, 



PAGE 


17 


18 


18 


19 


20 


21 


. 


! i 


. 


. 


. 


. 


. 


30 


31 


3] 


33 


. 


34 


• 


37 


38 


39 



Xll CONTENTS. 



CHAPTER II. 

PAGE 

Caries of the Teeth, ....... 41 

Causes of Caries, . . . . . . 51 

Predisposing causes of Caries, . . . .51 

Exciting causes of Caries, .... 

Comparative liability to Decay, . . . .62 

Consequences of Caries, ..... 63 

Treatment of Caries, . . . . . .66 



CHAPTER III. 

General Remarks on Filling, . . . . . 71 

Materials for Filling, ...... 

Lead, ....... 

Tin, ....... 80 

Silver, ....... -1 

Platinum, ....... 

Gold, ....... 83 

Various Preparation 

Crystal Gold, ..... 86 

Amalgam, . . . . . . >* 

Nonmetallic Material*, . . . . . |] 

CHAPTER IV. 

Instruments for Filling. ...... 

Heavy Cutting Insiruim .... 

Drills, ........ 

Bur Drills, ...... 96 

Common Drills, . . . . .98 

Drill Stocks. ...... 100 

Broaches, . . . . .101 

Excavators,. . . . . joi 

Manufacture of Exeavators. . . . .105 

Plugging Instruments. ..... 106 



CONTENTS. 



Xlll 



The File, 

Use of the File, 

Mode of using the File, 



PAGE 

111 
113 
114 



Separation of the Teeth, 



CHAPTER V. 



US 



CHAPTER VI. 



Filling of Teeth, 
mination, 
Opening Cavities, 
Removal of Decay, . 
Forming Cavities, 
Drj 
Introducing tl.- 

Block Billing, 

Forming Blocks, . 
Introducing the EN 

Finishing Filling . 



124 
125 
[26 
L28 
131 
139 
1 12 
1 \% 

149 

161 

154 
164 
158 
162 



OHAPTEB vn. 

ii of Decayed Cavities, . 

Fill and Modihcntii 

First Class, 

Filling with Foil, . 
Adhesive Foil, 
( Irystal Gold, 
1st Modification, 
2d Modification, 

. 
l.-t Modification, 



1GG 
166 

1G8 
173 

175 
177 
177 
179 
180 
181 



XIV CONTENTS. 

PAGE 

Third Class, 183 

. 2d Modification, ..... 186 

Fourth Class, . . . . . .187 

1st Modification, . . . . . 191 

2d Modification, . . . . . .193 

3d Modification, . . . . . 194 

4th Modification, . . . . .195 

Fifth Class, 197 

Special Cases, . . . . .199 

The Palatal portion of the Crown broken away, 
leaving the outer portion standing — nerve not 
exposed, ..... 200 

Filling large Cavities on the Labial Surfaces of 

the Superior Incisor, .... 204 



CHAPTER VIII. 

Pathological Conditions, ..... 206 

Treatment of Inflamed Dentine, . . . .210 

Tannin, or Tannic Acid, ..... 213 

Creosote, or Carbolic Acid, . . . . .214 

Nitrate of Silver, . . . . . . 214 

Chlorid of Zinc, . . . . . .216 

Terchlorid of Gold, . . . . . 217 

Arsenious Acid, . . . . . .218 

Alkaline Caustics, ...... 220 

CHAPTER IX. 

Exposed Pulps, ....... 221 

Treatment of Exposed Pulps, . . . . 223 

Destruction of the Pulp, . . . . .231 

Actual Cautery, ..... 236 

Potential Cautery, . . . . . .237 

Arsenious Acid, ..... 237 

Application of, .... 239 



CONTENTS. 



XV 



Filling Pulp-Cavities and Canals, 
Preparing the Teeth for Filling, 
Alveolar Abscess, . 
Treatment of, 



PAGE 

244 
251 
259 
261 



Pivot Teeth, 



CHAPTER X. 



Fitting the Crown, 
Attachment of the Crown, 
Metallic Pivots, . 



268 
272 
275 
279 



CHAPTER XI. 

Extraction of Teeth, 
General Remarks, 
Indications for Extraction, . 
Extracting Instruments, 

The Key, 

Modus Operandi, 

The Forceps, . 

Elevators, . 

Hooks, .... 

The Screw, 

The Gum-Lancet, 
Method of Lancing the Gums, . 
Extraction of the Teeth, 

Superior Incisors, . 

Superior Cuspids, 

Superior Bicuspids, 

Superior Molars, 

Extraction of Roots, 

Removal of the Dentes Sapientiae, 

Extraction of the Inferior Incisors, 
Roots, 

Inferior Cuspids, . 

Inferior Bicuspids, 



285 
285 
292 
294 
295 
296 
299 
311 
312 
313 
315 
317 
319 
319 
321 
323 
326 
327 
329 
331 
332 
332 
334 



XVI 



CONTENTS. 



Inferior Molars, ..... 

Inferior Dentes Sapientiae, .... 

Extraction preparatory to the Insertion of Artificial Den- 
tures, ...... 

Conditions to be observed in the Extraction, 



PAGE 

335 
339 



340 

342 



CHAPTER XII. 

Accidents in the Extraction of Teeth, . 
Hemorrhage, .... 

Treatment, 
Fracture of the Alveolus, 
Laceration of the Gums, 
Breaking the Teeth, 
Removal of a Wrong Tooth, 
Dislocation of the Inferior Maxillary, . 
Syncope, .... 



347 
34S 
350 
358 
360 
361 
3C2 
363 
365 



CHAPTER XIII. 



Anesthetics, .... 
Ether — Chloroform, 
Local Anesthesia, 

Congelation, 
Extraction by Electro-Magnetism, 

Application, 



368 

372 
373 
375 
377 



OPERATIVE DENTISTRY. 



CHAPTER I. 

INTRODUCTION. 

As introductory to the following treatise, a cursory 
consideration of those conditions and diseases of the 
teeth which demand the aid of dental surgery, would 
seem appropriate. To refer, however, to all of these, 
or to remark extendediy upon any of them, would 
not be consistent with the design of this work, or 
necessary to a proper understanding of the subjects 
proposed. Only those affections which pertain to the 
teeth directly, and which, for the most part, are con- 
fined to the tooth-substance itself, will here require 
attention. Nor will the pathology of contiguous 
parts be introduced ; for the appropriate treatment of 
these, being mainly therapeutic rather than surgical, 
would involve a discusssion of questions not within 
the scope of the present volume. Indeed, it is pro- 



18 INTRODUCTION. 

posed merely to speak of those affections of the teeth, 
which generally suggest surgical remedies, and which 
are implicated more or less in the operations de- 
scribed in the following pages ; and first, of 

DEPOSITS. 

In this term are included those calcareous forma- 
tions commonly called tartar, a certain coloring mat- 
ter denominated green stain, and such other impuri- 
ties on the teeth as result from neglect, the use of 
tobacco, and like causes. The word 



TARTAR 

Implies all calcareous deposits upon the teeth. Of 
this substance there are several varieties, the more 
obvious of which have respect to color and consist- 
ence. In color, there are all shades, from a white as 
light as that of the tooth, or even lighter, to a jet 
black ; and in consistence, all degrees, from a thick, 
gummy mucus, to the density of the dentine itself. 
The color will, in most cases, be indicative of the 
density, the lightest shade corresponding with the 
softest, and the darkest with the hardest consistence. 
The tenacity to the teeth is also in proportion to the 
density, the dense and dark adhering most firmly. 
The density of the deposit, too, is generally indicative 



TARTAR. 19 

of the rapidity of its formation, being in an inverse 
ratio to this. 

All the varieties of tartar are composed princi- 
pally of the same elements, — phosphate of lime, 
fibrin, fat, and animal matter being contained in 
them all, though in various proportions. The fact 
that some varieties are soluble in acids, and others 
not, has been adduced to prove that they are en- 
tirely different in their composition. This, however, 
is accounted for on an other hypothesis : in the softer 
varieties, the phosphate of lime is so protected by 
the fat and the animal matter that, under ordinary 
circumstances, acid can not come in contact with it; 
but the dense varieties are very soluble, because the 
acid readily comes in contact with the calcareous 
portion. 

Its origin. — It is a precipitate of the saliva, — or 
at least the phosphate of lime, and probably the 
fibrin, comes into the mouth with the saliva ; while 
perhaps the fat and other animal matter are depo- 
sited from the mucus. In all cases in which this 
substance is formed upon the teeth, the saliva has a 
very definite alkaline character, holding in solution 
the phosphate of lime, which, by the action of the 
acid mucus upon the saliva, is precipitated. 

Persons of a lymphatic temperament, or a ten- 
dency toward it, with muscles of a soft, flabby text- 
ure, hair light, teeth of a rather inferior quality, 



20 INTRODUCTION. 

and a free flow of saliva, are most subject to the de- 
position of tartar; yet there are conditions of almost 
all constitutions, in which it is freely eliminated. 
That it is precipitated from the saliva, is a far 
easily demonstrated and so generally admitted, that 
it need not here be considered. 

Points of Deposit. — The points at which it is depo- 
sited in the greatest quantities upon the teeth, are in 
the vicinity of the orifices of the salivary duets: and 
hence it is found most abundant on the inner porti 
of the inferior anterior teeth, and on the buccal 
faces of the superior molar-. Frequently, al><>. it 
collects in considerable quantities upon the external 
surfaces of the inferior front teeth. The points upon 
the teeth to which it most readily attache-, are at 
the necks, immediately beneath the five mi _' 
the gum, and at the termination of the enamel. A 
nucleus once formed, and it encroaches upon the 
crown o[ the tooth, if no means are employed to pre- 
vent its lodgment, at a rate determined by the con- 
dition of the saliva. 

It is deposited first and most abundantly on the 
necks of the teeth, because here the saliva fire! 
in contact with tb ms. and here rem 

the longest periods and in the largest (plant'. 
That it is precipitated very Boon after the saliva 
enters the mouth, is evident from the fact that it is 
found collected upon the superior molars, just in the 



TARTAR. 21 

vicinity of the orifices of the ducts-of-Wharton, where 
the saliva cannot be retained for any considerable 
time, by reason of the position, but must very soon 
pass along upon the surfaces of the contiguous teeth, 
on which we generally find it deposited in much 
smaller quantities. Indeed, this calcareous deposi- 
tion has been sometimes found in the salivary ducts 
themselves. 

Its Effects. — It exercises no directly injurious influ- 
ence upon the substance of the teeth ; but it is highly 
prejudicial to the parts immediately in connection 
with them, upon which they depend for support. It 
encroaches upon the gums and alveoli, and causes an 
absorption of these important surroundings; and as 
they become absorbed, its encroachments are accele- 
rated. In some constitutions this process goes on 
with little or no annoyance to the patient; while in 
others, irritation, inflammation, and even suppuration 
of the gums occur; and thus their destruction is effected 
in a twofold manner. This irritation and inflamma- 
tion may extend to the mucous membrane, and in- 
volve all the adjacent parts. The dental periosteum, 
also, if susceptible, as in many cases it is, will become 
implicated in the difficulty; periostitis will ensue, 
and often suppuration, thus breaking up the attach- 
ments of the teeth even before the surroundings are 
removed. The alveolus, too, becomes diseased, and 
in some instances its death and exfoliation result. 



22 INTRODUCTION. 

Salivary calculus, however, never induces caries of 
the teeth, nor even favors it. On the contrary, 
frequently meet with instances of decay entirely ar- 
rested by a deposit of tartar in the cavity. 

Persons of all ages are subject to this affect i 
those past middle life - . and t. 

advanced in years sometimes havii i nearly 

covered with tartar. There are some constitutions 
whose diathesis is favorable to a deposition of sali- 
vary calculus through life, ()th in. will be 
perfectly exempt from it till b culiar constitu- 
tional change intervenes, when it will begin to 
rapidly eliminated. 

Method of removing If. — Tb salivary 

calculus Is an operation that d involve 

amount of skill, but. with suitable appliance s 
easily performed. There are two meth< a 
ing it; tlie one. that (^ sealing and scraping, and the 
other, that of decomposing the deposit by the appli- 
cation of an acid. The former is al i be pre- 
ferred; for. in the latter, the chemical action o( the 
acid does not stop with a decomposition oi' the 
posit, but. by the same affinity, attacks the ( 
itself. For the successful accomplishment o( the 
operation, instruments of various forms and curves 
will be necessary, adapted and adjusted to the 
various shapes and situations ol % the Burfao - 
operated upon. The most common forms are r 



TARTAR. 



sented in the following figure. The blade of the in- 
strument should be applied at a slightly obtuse angle 
with the surface of the tooth, just beyond the edge of 



Fur. 1. 




the deposit next the gum, and thus slid under the 
tartar, scaling it off to the point, in such a manner 
as not to roughen up or abrade the enamel. Deposits 
of this substance on proximal surfaces of the teeth 
are to be carefully observed, and removed with in- 
struments of attenuated blades. When the thick 
incrustations have been thus removed, the surface 
should then be gently scraped, so as entirely to clean 
off all remaining portions, and afterward thoroughly 
polished with fine pumice, or Arkansas- or rotten-stone, 
and finished by burnishing. During the operation, a 
frequent employment of the toothbrush with water 
will be required, to cleanse the mouth of the detached 
deposits and the increased secretions; and, in general, 
the completion of the process will occupy more than 
one sitting. Since this deposit often extends beneath 



24 INTRODUCTION. 

the free margin of the gum, much care is necessary 
to see 'that it all be removed. 



GREEN TARTAR. 

This deposit has been so referred to by writers, as 
to convey the impression that it is of the same 
generic character as salivary calculus. Such a mis- 
apprehension is hardly pardonable. The teeth of 
young persons only are subject to this affection, it 
being often found on those of children three or four 
years old. It almost always appears on the labial 
surfaces of the superior front teeth, and in largest 
quantity near the margin of the gum. It is seldom 
seen on the inferior teeth, and only on the anterior 
surfaces of the superior. The color of this deposit is 
very dark, inclining to green. Wherever it attaches, 
the surfaces of the teeth are abraded, and when it is 
of long standing, the entire enamel beneath it is 
destroyed, and the dentine is gradually involved in 
the dissolution. This effect upon the teeth is not 
produced by the coloring matter observed upon them, 
but by an acid in combination with this material 
before it is deposited. The stain is a precipitate 
from this compound, and the acid, leaving this, com- 
bines with the calcareous ingredients of the teeth, 
to their detriment as above; but the precipitate is 
entirely innocent. 



GREEN TAKTAR. 25 

Its Origin. — Green tartar, or green stain, doubtless 
has its origin in the mucus, when this is in a particular 
acid condition. That it does not proceed from the 
saliva is proved by the fact that it is never found 
where there is a free flow of saliva, or where this has 
free access ; but the point of its deposit is where the 
saliva is least frequently present, being most abun- 
dant in cases in which there is a large relative 
amount of mucus, and this in a very acid condition. 
But the query might arise here, if the mucus of the 
mouth were wholly in that condition, why would not 
the teeth suffer from it elsewhere. Because, on the 
masticating surfaces of the teeth, the friction of the 
food will prevent it, and on the inner surfaces, the 
friction of the tongue ; besides, wherever there is a 
free flow of saliva, this will have a counteracting 
effect. Decay goes on very rapidly, after it has once 
commenced, upon teeth affected by this deposit. 

There are points of dissimilarity between this green 
tartar or stain and salivary calculus, that it may be 
well to notice. The latter is from the saliva ; the 
former from the mucus; and hence the one exists 
where there is an abundant flow of saliva, and the 
other where the relative quantity of this is small. 
The calculus is deposited when the saliva is in an 
alkaline condition ; the stain, when the mucus is 
very acid. The former is deposited in large quanti- 
ties and thick incrustations, and upon the surfaces of 



INTRODUCTION. 



the teeth, and is easily removed without detriment 
to their substance ; whereas the latter is a thin film, 
barely sufficient to stain the surface, and yet it enters 
into the tooth-substance itself, and cannot be removed 
without detaching some portion of the tooth with it. 
The one seems rather preventive of caries, which 
does not occur beneath it ; but the other is highly 
promotive of decay. With these marked features 
of difference, it is surprising that the two should 
ever have been confounded, since it is so important 
that the distinctive character of each be understood, 
in order to its correct treatment. 

Treatment. — In order to a perfect and final remedy 
for green stain, therapeutic treatment must be com- 
bined with the operative ; but only the latter will be 
here described, which has for its object the removal 
of the deposit, and the rendering of the eroded sur- 
face smooth and polished. There are two or three 
methods of accomplishing this object. When the 
erosion is but slight, it will be effected with pul- 
verized pumice or Arkansas-stone, applied with water 
till the stain disappears, and with the subsequent use 
of the burnisher with a solution of soap. But when 
the erosion is too extensive to be thus reduced, it 
must be cut down with a file, and then finished with 
stone and burnisher, as before. And when the ero- 
sion is extreme, a cutting-instrument must precede 
the file. 



IRREGULARITY. 27 



IRREGULARITY. 



By this term we imply those variations from a 
beautiful and natural position, in which the teeth are 
so frequently found. The principal cause of irregu- 
larity is a disproportion between the actual size of 
the arch, and the size required for the accommoda- 
tion of the teeth. When this disproportion exists, 
the teeth which are first irrupted, occupy very nearly 
their proper position ; but those which come in after- 
ward, are more or less disarranged, in proportion to 
the preoccupation of the space. There are cases in 
which the roots of the temporary teeth are not ab- 
sorbed, and the permanent teeth are irrupted out of 
their true position, even when there is room enough 
for them were the former removed. Irregularity is 
mainly confined to the front teeth, and consists in 
either an inward or an outward inclination, and, in 
some instances, both. Sometimes the incisors are 
turned round in the socket, so that the edge stands at 
a very considerable angle with the proper position. 

The upper teeth are oftener materially disarranged 
than the lower, though the latter frequently exhibit 
some irregularity in front, in consequence of a 
crowded condition. The teeth most liable to be out 
of position are the cuspidate. These, of the teeth of 
replacement, are the last in their irruption ; and it 
often occurs that the arch is previously wellnigh oc- 



28 INTRODUCTION. 

cupied ; in which case they are thrown outward. 
When there is any irregularity of the bicuspids, it is 
that of an inward inclination. The first and second 
molars are very seldom out of proper position. The 
third molars, however, for want of room, are some- 
times thrown out toward the cheek, or even pre- 
vented from coming out at all in any direction. 

Effects. — In all cases, irregularity is favorable to 
decay. It is even maintained by some that the 
organic structure of irregular teeth is less perfect 
than that of regular, because the former are impeded 
in their irruption, and thus impaired. But this, to 
say the least, is questionable ; for it will be remem- 
bered that the crowns of the teeth are formed and 
completely ossified before they can be affected by a 
crowded state ; and it is hardly probable that they 
could be materially modified in their structure after 
this period. The crowns of the teeth are never de- 
formed by a crowded condition. The principal cause 
of the liability of irregular teeth to decay, is the fa- 
cility they furnish for the lodgment of foreign sub- 
stances about them, and the difficulty they present to 
its removal. And again, in irregular teeth, parts are 
approximated that nature did not intend should be 
brought together. Irregularity impairs the speech, 
impedes the mastication, and often distorts the coun- 
tenance and deforms the features. 



mm 



ATROPHY. 29 



ATROPHY. 



This affection is characterized by defective spots in 
the enamel, white, chalklike — which scarcely ever 
penetrate the dentine. In these spots there is 
nothing of that organic structure exhibited by well 
formed enamel. They are in all cases quite small, 
but vary greatly in number. They are often found 
arranged in transverse rows across the tooth affected. 
The superior incisors are most frequently found with 
atrophy, though the bicuspids and molars sometimes 
exhibit it. The front upper teeth are attacked by it 
only on the anterior surfaces. 

Instead of the spots, we sometimes find pits, or 
indentations, into or through the enamel, which occa- 
sionally run together, so as ultimately to form trans- 
verse grooves of considerable extent upon the teeth. 
In many cases, where on the irruption of the teeth 
the spots only are presented, the organs are not 
injured, except in appearance, the spots retaining 
the smooth, enamellike surface during life. In other 
cases, the spot is of such a soft, friable texture, that 
it early crumbles out, leaving the little pits above 
referred to. These indentations, however, sometimes 
exist at the first appearance of the tooth, but more 
frequently afterward, being formed by the crumbling- 
away of the defective portion. 

Atrophy usually occurs on teeth of good structure, 



30 INTRODUCTION. 

short, thick crowns, and rather yellowish color. The 
long, thin, white tooth, of imperfect organization and 
insufficient density, seldom or never presents an atro- 
phied condition. 

The Cause. — It may be difficult to point out the 
precise cause of this affection, but some facts in re- 
gard to it are very obvious. There is, in every case, 
an obstruction in the development of the enamel at 
the point of defect, and at the time of its origination. 
In some cases, doubtless, there are a deficient amount 
and an inferior quality of the material elaborated for 
the upbuilding of the structure; and this is probably 
the case when the pits exist at the irruption of the 
teeth. In other instances, the requisite quantity of 
material may be elaborated, and yet the vital energy 
be insufficient to organize it, as in the case of the 
spots referred to. The latter condition is more fre- 
quent than the former, as is evidenced by the more 
frequent appearance of the spots than of the pits. 
We are led to infer, then, that the origin of this 
affection is for the most part constitutional, and not 
local. There are commonly found traces of it on all 
the teeth whose enamel was in process of formation 
at the time of the interruption. 

Any general disturbance, such as to interrupt the 
assimilative process, would be detrimental to the per- 
fect formation of the tooth. Again, some affections 
may materially affect the organizing power of the 



EXOSTOSIS. 31 

system, without interfering with the assimilative 
power. Any disease that should interrupt the func- 
tions of the digestive apparatus, would be prejudicial 
to the process of assimilation ; whilst other diseases, 
such, for instance, as those of a febrile character, 
would diminish the vital power, and consequently 
the ability to build up organic structures, without 
interrupting in any special manner the process of 
assimilation. These things are referred to here for 
the purpose of showing under what circumstances 
atrophy of the teeth may occur. 

Effects. — In the best formed teeth, there are no 
unpleasant results from atrophy, other than its de- 
traction from their beauty. The spots are unsightly, 
and when the pits are present, they become dark, 
and sometimes black, from deposit ; which, by ordi- 
nary means, is difficult of removal. In teeth of infe- 
rior structure, decay often supervenes in these pits, 
and, extending thence, involves the other parts ; and 
anything that will affect the tooth-substance, will 
affect the spots in a greater degree. 

EXOSTOSIS. 

This term, critically defined, implies outgrowth from 
a hone ; but, as applied to the bones generally, and 
particularly to the teeth, it probably conveys the idea 
of growth upon a hone. The affection thus denomi- 



32 INTRODUCTION. 

nated is common to all the bones; some, however, 
being more frequently attacked by it than others. 
It occurs upon the roots of the teeth, but is never 
developed where there is no periosteum. The man- 
ner of its deposit is not uniform ; but it is commonly 
in an enlargement on the point of the root, or from 
the point some distance toward, and occasionally all 
the way to, the neck of the tooth. In some cases, it 
extends entirely round the root, and in others, is con- 
fined to one side. It sometimes results in such an 
enlargement of the root, especially if it is near the 
point, as to render the tooth very difficult of removal. 
When it is bulb-form, the entire attachment of the 
tooth may be broken up, so as to allow this to rotate 
in the socket, and yet the tooth be very difficult to 
remove ; indeed, in some instances, impossible, with- 
out cutting away a portion of the process. 

The density of the deposit is usually greater than 
that of the root on which it is found ; though in this 
respect there is considerable variation : in a few in- 
stances we have found it softer than the root proper. 
The surrounding parts are absorbed for its accommo- 
dation. The color of the substance is slightly yellow, 
not differing much from that of the root itself; and 
frequently it exhibits a semitranslucent appearance. 
The rate of its formation varies considerably, some- 
times increasing so rapidly as to occasion much diffi- 
culty, and at other times seeming to advance very 



EXOSTOSIS. 33 

slowly ; and frequently it is arrested altogether. 
Hoots are often found affected with exostosis, that 
have been dead and crownless for a number of years, 
and yet have never, so far as known, given any trouble 
because of the affection ; and teeth perfectly healthy 
in other respects may be thus affected. 

Its Effects. — It always increases the difficulty of re- 
moving the tooth, either by enlargement of the point 
of the fang, or by deposit upon one side of it, causing 
it to curve ; in which latter case the difficulty is all 
the greater, from the impossibility of determining the 
direction of the curve. It sometimes produces a dis- 
eased condition of the surrounding parts — in some in- 
stances chronic inflammation — that will continue as 
long as the tooth remains. Nervous affections often 
result from exostosis, either through irritation caused 
by pressure on the nerve, or through the diseased 
condition of the surrounding parts. The floor of the 
antrum is sometimes absorbed away, in consequence 
of the enlargement of the point of the fang; and 
then disease of the lining membrane of that cavity 
generally ensues. 

The Cause. — The cause of this affection is not well 
understood. It is most probably deposited by the 
periosteum when this is in an abnormal condition ; but 
what peculiar condition, it is not clearly ascertained, 
though some have supposed it to be inflammation. 
It is patent, however, that something more than a 



34 INTRODUCTION. 

state of simple inflammation exists ; for there is in- 
flammation in numerous instances without this de- 
posit. Again, in all cases where there is periostitis, 
that state is definitely indicated by percussion upon 
the affected tooth; indeed, in the occlusion of the 
jaws, pain is usually experienced. Yet there are 
found many teeth whose roots are subjects of this 
deposit, that have never given any indications, either 
by pain or otherwise, of a diseased condition. 

This subject is one in which there is room, at least 
so far as dentists are concerned, for extensive obser- 
vation. 



DENUDING. 

This consists in a wasting-away of the enamel of 
the anterior teeth, from the points toward the necks. 
The affection, however, is of too rare occurrence to 
demand extended consideration. The color of the 
enamel is not changed by this process, nor is its 
natural polish impaired by any abrasion. The den- 
tine, on becoming exposed by this removal of its 
natural protection or covering, is perfectly smooth, 
but of a yellowish cast, in some cases inclining to 
brown. When the enamel is removed, there seems 
to be a cessation of the destructive process ; for the 
crowns of such teeth will, in many instances, endure 



DENUDING. 35 

for a long time — indeed, till they are worn down by 
the friction in mastication. 

This wasting process usually begins at the points 
of the teeth, and proceeds toward the necks, on all 
sides, till the enamel is entirely destroyed. Some- 
times, however, it commences on their labial sur- 
faces ; this is particularly the case with the superior 
anterior, but very seldom with the inferior teeth. 
The affection, however, attacks the inferior more fre- 
quently than the superior teeth ; yet it is often found 
assailing both with about equal energy. 

The cause of the disease is not well understood, 
though it is generally conceded to be the operation 
of an acid contained in the mucus. Doubtless, the 
agent producing the affection is contained in the 
mucus ; for it usually occurs where there is a large 
relative amount of this secretion ; but that it is an 
agent of a very decided acid character, we are not 
prepared to affirm. Decay of the teeth does not seem 
to progress with greater rapidity while this affection 
exists, than at other times; and again, the enamel 
does not present the roughened, abraded appearance 
we find resulting from the operation of any ordinary 
agent. With these apparently incongruous facts, it 
is rather difficult to arrive at a definite conclusion as 
to the precise manner in which this condition is pro- 
duced, or the exact character of the agent instru- 
mental in its production. 



36 INTRODUCTION. 



CHEMICAL ABRASION. 



This consists in a gradual destruction of the entire 
substance of the crown of the tooth — the enamel and 
the dentine. It is an affection of comparatively rare 
occurrence. It assails the superior more often than 
the inferior teeth, though both are subject to it. It 
begins upon the points of the central incisors, wast- 
ing them away most rapidly at the median line, from 
which it progresses each way, involving the lateral 
incisors, cuspids, and sometimes the bicuspids, so that 
a curved line is presented by the edges of the teeth, 
of greater or less inclination, according to the rapidity 
of the process. When the superior teeth only are 
affected, the opening between the ends of the upper 
and of the lower front teeth, when closed, is a semi- 
ellipsis. If the inferior teeth are affected, as is some- 
times the case, then the opening will be an ellipsis. 

In the case of Mr. G., the affection had been in 
process about two years and a half; the wasting- 
away extended to the first bicuspids both above and 
below r ; and when the jaws were closed, the ends of 
the upper and of the lower central teeth were about 
one third of an inch asunder, and the opening was of 
the elliptical form. It w T as a mystery to him. Two 
years and a half before, his anterior teeth shut close 
together on the ends. He had not used them in the 
mastication of his food, for his molar teeth were all 



CHEMICAL ABRASION. 37 

good, and sufficient for this purpose ; and moreover it 
had been impossible for him to use them in mastica- 
tion, since he could not bring them together; and he 
had not been in the habit of putting any hard sub- 
stance between them. 

The Cause. — The cause of this affection, like that 
of denuding, is not well understood. It is supposed, 
however, to be induced by an acid contained in the 
mucus. If this supposition is correct, it must be 
some acid with whose nature we are but little, if at 
all, acquainted ; or, if any ordinary acid, it certainly 
must be modified by very peculiar circumstances. 
The surface upon which it acts is always perfectly 
smooth and polished, never presenting that rough- 
ened and abraded appearance caused by the action of 
any ordinary acid upon enamel or dentine. And 
again, if this affection results from the operation of 
an acid in the mucus, why does not this acid, to 
some extent at least, affect the teeth at other points ? 
Such is not the fact; and caries that has previously 
commenced at other points on the teeth, does not 
progress more rapidly during the existence of this 
disease, than before ; but it certainly would, if there 
were a large quantity of acid in the mucus. 

It has been supposed that the mucous follicles of 
that part of the tongue which comes in contact with 
the teeth at the affected part, are the agents that 
produce the disease. Of this, however, there is not 



38 INTRODUCTION. 

evidence sufficient to warrant an adoption ol the 
theory. The cupping of the molars and cuspids 
bears strong indications of being an analogous pro- 
cess, and yet no such influence can exist for its ac- 
complishment. We have no theory on this subject 
to present, regarding it as still an open field for in- 
vestigation. There can be little doubt, however, that 
the cause of denuding, of chemical abrasion, and of 
cupping, has its origin in the constitution, is not 
merely local, and may be removed, and the affection 
arrested, by constitutional treatment. 

NECROSIS OF THE TEETH. 

By this term is understood the death of the part 
affected. It has been remarked that the condition is 
similar to mortification in the soft parts of the sys- 
tem. But in the latter there occurs a change of 
structure ; whereas, in the bones, and particularly in 
the teeth, there is not necessarily any change conse- 
quent on the loss of vitality. The teeth have their 
organic connection with the surrounding parts by the 
external and the internal periosteum and the pulp ; 
their crowns depend for vitality upon the internal 
organism ; and when this is destroyed, they are 
wholly necrosed, or deprived of vitality, as is evident 
from the total loss of sensibility in them immediately 
after the destruction of the pulp. 



NECROSIS OF THE TEETH. 39 

Necrosis of the teeth differs from that of the other 
bones in some particulars, one of the most obvious of 
which is, that in the former there is no exfoliation, 
the living structure not having the power to throw 
off the dead or necrosed portion. Again, a dead part 
in contact with the living, does not materially affect 
it. The roots of the teeth depending for their vi- 
tality upon both their internal and their external 
connections, the former of these connections may 
be destroyed, without materially affecting the latter. 
Thus, a tooth may be partially necrosed, — that is, 
vital in one part and dead in another, — without im- 
mediate injury to the living portion, and without 
separation of the living from the dead. It is a happy 
provision that the analogy between the teeth and 
the other bones does not, in this respect, obtain ; for 
if it did, we should find the crowns of the teeth exfo- 
liated from the roots in all cases, immediately after 
the death of the pulp. 

There results but little change of color to the teeth 
from necrosis, unless coloring matter is absorbed by 
the dentine from the decomposed pulp; though of 
course the lifelike lustre and appearance of the 
living teeth are not present. Total necrosis destroys 
the entire organic connection of the teeth with the 
surrounding parts ; in which case they are imme- 
diately expelled from their sockets as useless. 

Causes. — Caries is a very common cause of ne- 



40 



INTRODUCTION. 



crosis, especially the partial form of it to which 
reference is made above. Protracted fever, or dis- 
eases of any kind that diminish the vitality of the 
constitution, will in a corresponding degree diminish 
that of the teeth, and sometimes destroy it entirely. 
Excessive medication, especially with mercurials, will 
sometimes produce partial, and occasionally total ne- 
crosis, as will also sometimes blows or violent shocks, 
when these are not sufficient to displace the teeth. 
Great and sudden changes of temperature have been 
reckoned causes of this affection ; but it may well be 
doubted whether they are adequate, without the con- 
currence of other influences. 



CHAPTER II. 

CARIES OF THE TEETH. 

Notwithstanding the teeth are so important in 
the human economy, having functions so various and 
so extensive to perform, they are greatly neglected 
in most instances, and, in many subjected to positive 
violence ; as, for example, in crushing or biting hard 
substances, sustaining weights, and suffering severe 
percussion, sudden extremes of temperature, bungling 
dental operations, etc. Very few give that attention 
to these organs, which is requisite to preserve them 
from injurious influences ; and, owing to artificial 
modes of life, and consequent impairment of health, 
this is often difficult to do. Indeed, these influences 
are frequently not known, and the causes of disease 
in the teeth not explored. 

Such is the truth, to some extent, in regard to 
caries ; though this affection is more generally a re- 
sult of conditions well understood. The dentine is 
affected more frequently by caries than by any other 
form of disease. It is both frequent in occurrence 
and fatal in tendency. Scarcely any that have at- 



42 CARIES OP THE TEETH. 

tained maturity, are exempt from its ravages. It is a 
disease which the resisting forces can but feebly 
withstand, and in which the recuperative powers are 
of no avail. Some maintain that softened dentine 
does in many cases regain its normal density ; but 
this cannot be, unless it retains its vitality. But 
any agent possessed of sufficient energy to decompose 
the dentine, will destroy its vitality. What is that 
decomposition ? Either a lack of vital power to 
maintain the integrity of the organic structure, or 
the action of some agent having an affinity for a cer- 
tain part of the dentine more potent than that vital 
power. In either case, the vitality is destroyed. In 
an organized structure, removal of one of its compo- 
nent parts occasions a loss of vitality in the rest. 

Caries makes its first attack upon the dentine, and 
progresses most rapidly in the direction of the tubuli. 
There are variations from this course ; as, for exam- 
ple, in the large superficial caries on the labial sur- 
faces of the superior incisors. In many cases, too, it 
advances immediately beneath the enamel. Portions 
of the dentine imperfectly protected by the enamel, 
on account either of an injured condition or of an im- 
perfect formation of the latter, are liable to be at- 
tacked by this disease ; and points that, by their 
location or any other unfavorable circumstance, re- 
tain injurious agents in contact with the tooth, are 
very subject to decay. 



CARIES OF THE TEETH. 43 

The attack and progress of caries are modified by 
the constitution of the teeth. These may be defec- 
tive either originally or accidentally. Original de- 
fectiveness would extend to all the teeth of the same 
individual, whilst accidental might exist only as to 
some of the teeth in the same mouth, and these only 
at particular points. Such conditions are peculiarly 
favorable for the attack of caries. When the whole 
crown of the tooth is imperfectly organized, the decay 
will advance with uniform rapidity, till the whole is 
destroyed. But when it is only portions of the tooth, 
the caries, after a time, becomes retarded in its prog- 
ress, and in some cases checked altogether. 

Among the circumstances which modify the prog- 
ress of this disease, are, a change of the condition 
or character of the agencies producing it, and an 
increase or a diminution of the amount of such agen- 
cies. The progress of caries will also be governed 
somewhat by the age of the person whose teeth it 
attacks, and by the peculiar constitution of the 
organs themselves; for, in regard to constitution, 
these present an almost infinite variety, the relative 
proportions of their constituents being exceedingly 
various, even in persons of the same age, and con- 
tinually varying in the same person at different ages. 
There is a constant change going on, the calcareous 
elements increasing, and the animal decreasing. But 
a proper relative amount of elements may be elabo- 



44 CARIES OF THE TEETH. 

rated, and yet a defective organization exist. This 
condition arises from inipotency of the organizing 
power, or from a failure of the materials to arrange 
and combine ; and it is dependent entirely on acci- 
dental causes. In vital energy, indeed, the teeth 
exhibit great diversity ; and this corresponds with, 
and to some extent depends upon, the vital energy 
of the general constitution. Dead dentine is decom- 
posed more readily than living ; and hence the con- 
clusion that vitality resists caries, and that this re- 
sistance corresponds with the vigor of the vitality. 

The points most frequently attacked by caries, are 
the proximal surfaces of the teeth, the indentations 
and fissures on the masticating surfaces of the 
molars and bicuspids, the longitudinal depressions 
on the buccal and palatal walls of the molars, and 
the necks of the teeth at the termination of the 
enamel. On the proximal surfaces, the enamel is 
thinner than elsewhere ; and the situation is pecu- 
liarly favorable for the accumulation and retention 
of injurious agencies. The union of the enamel in 
the fissures and indentations of the crowns of the 
molars, is often imperfect ; and thus there is a way of 
entrance for vitiated fluids 'to the dentine. Decay is 
found at the terminations or intersections of these 
fissures earlier than at any intermediate points. The 
indentations, or grooves, on the sides of the teeth, are 
usually attacked by caries at that point next to the 



CARIES OF THE TEETH. 45 

neck. Less frequently, the disorder is exhibited at 
the neck, just beneath the border of the enamel, 
under which it burrows with a transverse extension. 

The order in which the elements are removed, is 
governed by the nature of the agency which effects 
the decomposition ; and this is usually one having an 
affinity for the calcareous elements strong enough to 
destroy the texture of the dentine, and remove the 
earthy portion. Those acids which have an affinity 
for the lime of the dentine, produce its decomposition 
in this manner. When the decay is thus caused, 
the portion remaining in the cavity is soft, and 
approximates the gelatinous condition as the cal- 
careous material is abstracted. Agents of a different 
character, too, often produce decay. Alkalies will act 
upon the animal portion of the dentine, and remove 
it ; and in caries thus produced, the residue is friable 
and chalklike. In other cases the constituents are 
simultaneously removed. Nitric acid will cause an 
entire breaking-up of both the earthy and the animal 
constituents. Death of the dentine generally induces 
decay, decomposition being more, easy after the 
vitality is lost. But th§re are exceptions to this. 

The dentine outside of the decay may be in an in- 
flamed and irritable condition, so that contact with 
the decayed portion will produce pain ; and thus we 
may be led falsely to conclude that the softened den- 
tine is sensitive; and, indeed, it is maintained that 



46 CARIES OF THE TEETH. 

in some cases the partially decomposed dentine is so, 
on the supposition that a small portion of the calca- 
reous elements may be removed, and yet the fila- 
ments of the nerve ramifying the part, not be de- 
stroyed. 

The progress of caries is far more rapid in the 
crowns of the teeth than in the roots, for the reason 
that the former are more exposed to the influences of 
external injuries. It is true that the crowns are 
covered by enamel, which is designed to shield the 
dentine from injury, but which is often defective, and 
on which are accumulated agencies that it cannot re- 
sist, even when it is perfect; so that the enamel itself 
is sometimes decomposed. The roots, too, posse- 
higher degree of vitality than the crowns, and their 
ability to resist the encroachments of decay is cor- 
respondingly greater; and hence we often find the 
roots of teeth solid and free from decay, the crowns 
of which have been removed by rapid decomposition. 
Injurious substances are sometimes pressed into con- 
tact with the dentine, through defects in the enamel, 
or under its projections, and there retained till their 
mischievous effect is produced. 

It is maintained by some writers that caries is con- 
tagious. Dr. Koecker was of this opinion. The 
question, then, is, whether there is any property in 
the decayed dentine of one tooth, capable of producing 
the same condition in the healthy dentine of an other. 



CARIES OF THE TEETH. 47 

The residue of abnormal dentine in the soft decay, 
consists of the animal elements and a small portion 
of earthy material ; and in decay in which the gela- 
tinous constituent is abstracted, the remainder is 
chalklike, consisting mainly of phosphate of lime. 
In neither of these is there anything that can possi- 
bly operate on the healthy dentine. There is one 
thing here, however, that is worthy of remark, and 
that has perhaps led to the mistaken notion that 
caries is contagious : decayed dentine will absorb and 
retain fluids that injuriously affect sound dentine ; 
and when the decay is on the proximal portion, two 
teeth are subject to the same exciting cause. But it 
is seldom that two teeth thus situated are both in 
the same stage of decay; a fact principally attributa- 
ble to the difference in their constitution. The decay 
of the teeth in pairs has also been adduced as evi- 
dence of the contagious character of the disease. 
This, however, results from the fact that the pairs 
are formed at the same time ; are subject to the 
same influences in their formation, and hence are 
constituted alike ; and if one of the pair is defective, 
the other will be in a like condition. When there is 
a vitiation of the saliva or mucus, they will be simi- 
larly affected. In no common acceptation of the 
term contagious, can it be applied to caries of the 
teeth. 

The color of caries is exceedingly various, from 



48 CARIES OF THE TEETH. 

that of healthy dentine, through every intermediate 
shade, to jet black. The rate of the progress is indi- 
cated by the color of the decay, being slower as this 
is darker, so that when the decay becomes almost 
stationary, the affected portion is black. The degrees 
of color are differently enumerated by different 
writers; as, by Koecker five, by others seven, and 
so on. Three, however, are sufficient for our pur- 
pose : white, brown, and black. The sensitiveness of 
the dentine is greatest in teeth affected by the white 
decay, and usually decreases as the color darkens ; 
though there are exceptions to this rule; for occa- 
sionally we find teeth affected by dark decay, that 
are quite sensitive. The light-colored decay is more 
difficult to arrest than the dark. In many cases of 
the former, filling seems hardly to retard its pro- 
gress; whereas, in the latter, by proper filling, the 
advance of the decay may be checked altogether. 
The cause of the dark color of caries is not perfectly 
comprehended. It is doubtless a deposit upon the 
decayed part, and is most probably a metallic oxyd. 
as iron, sodium, potassium, and calcium are found in 
the saliva and mucus in several combinations. 

The opinion is entertained by some, that this 
deposit protects the dentine from the influence of 
injurious agents. But this is most probably not cor- 
rect, at least to any perceivable extent. If the 
deposit does thus serve as a protection, the removal 



CARIES OF THE TEETH. 49 

of the discolored portion would subject the dentine to 
a renewed attack of caries, w T hich experience assures 
us it does not do, but that after some time it assumes 
the dark hue again. Those who maintain this 
opinion, refer, in support of it, to the fact that a 
deposit of oxyd of silver being made upon a decay 
of light color, by the use of nitrate of silver, the prog- 
ress of the decay is thereby retarded. This retardal, 
however, is effected more probably by a change in 
the character of the decay, than by any protection 
afforded by the coating of oxyd of silver. 

Some sensitiveness commonly accompanies caries. 
It does not often amount to pain, but is rather a 
sense of uneasiness; yet, when anything is brought 
in contact with the sensitive dentine, as sudden 
changes of temperature, acids, etc., intense pain may 
be produced. Dr. Koecker remarks that caries is 
most tender in its first stages ; and Dr. Cone, that 
when a tooth is attacked by it, the sensitiveness is 
increased. The surface of the dentine, or that part 
united to the enamel, is susceptible of the most acute 
sensitiveness, since here is the place of termination 
of the nerve-fibrils which ramify the dentine, and 
which, whether in a healthy or a diseased state, are 
more sensitive at their terminations than along their 
extent. When there is inflammation of the dentine, 
intense pain may be produced by the contact of an 
instrument, in a cavity of decay, at the line of union 



50 CARIES OF THE TEETH. 

of the dentine with the enamel, and very little sensi- 
tiveness be present elsewhere in the cavity. Sensi- 
tiveness of a uniform character sometimes pervades 
all parts of the cavity, while at other times it may 
be very intense at one point, and very slight or 
entirely absent at any other. A thin lamina of the 
dentine lining the whole cavity, may be uniformly 
sensitive, and in some cases this sensitiveness may 
involve the entire body of the dentine. 

By means of this sensitiveness, warning is trans- 
mitted to the pulp, which emits osseous material with 
increased energy ; and thus a process of filling up 
the natural cavity of the tooth is instituted, that the 
decay may not encroach upon the nerve. Bat this 
warning may, in some degree, be transmitted to the 
pulp, though there be no increase of sensitiveness. 

This sensitiveness is modified by the character of 
the teeth, the nature of the decay, and the state of 
the patient's constitution. The teeth of the same 
person will be more sensitive at one time than at 
another, because of a greater irritability of the ner- 
vous system. Those teeth which decay most rapidly, 
are usually most sensitive; though in teeth whose 
vitality is lost considerably in advance of their decay, 
there is no sensitiveness at all. Except in such cases 
as last mentioned, the whitest and most rapid decay 
has most sensitiveness, the brown much less, and the 
black scarcely any. 



CAUSES OF CARIES. 51 

CAUSES OF CARIES. 

The causes of caries of the teeth may be considered 
under two general divisions — predisposing and ex- 
citing. Of the former, some are original, others acci- 
dental. •The original development of the constitu- 
tion may be defective, either from original or from 
accidental defect in the parent; but more certainly 
from the former. Constitutional characteristics are 
transmissible, and a defect is as surely hereditary as 
anything else. In the fetus, during gestation, there 
may have originated germs from which perfect organs 
can never be developed, and these germs may be 
more or less defective according to the constitutional 
condition of the mother, or according to accidental 
conditions to which she may be subject, and which 
may seriously affect the fetus. After birth, too, the 
child is exposed to injurious impressions, which will, 
to a greater or less degree, render the development 
defective; as imperfect nourishment and the diseases 
and functional derangements peculiar to childhood. 
A diseased condition, or functional derangement, will 
interrupt the proper elimination and perfect upbuild- 
ing of the materials necessary for the perfect struct- 
ure ; and indeed anything that will disturb the 
equilibrium of action in the system, may be detri- 
mental to the teeth. 

In some instances the teeth will exhibit the pecu- 



52 CARIES OF THE TEETH. 

liarities of the mother, and in others, those of the 
father ; while sometimes they participate those of 
both parents ; and when the parental imprint is thus 
found stamped on the teeth, it will also be found that 
those of the same class decay at the same point and 
at about the same age as in the ancestor. In such 
cases the defect is manifestly hereditary ; it cannot 
be accidental : the coincidences thus constantly oc- 
curring preclude any other conclusion. Hereditary 
taint, then, may be regarded as a predisposing cause 
of caries. 

Impaired vitality is another predisposing cause ; 
and not only impaired vitality of the teeth and con- 
tiguous parts, but also that of the general system. 
Indeed, the vital vigor of the teeth depends upon 
that of the general system, and, when there is no 
local influence at work, corresponds with it ; so that 
when the general system is in the most healthy con- 
dition, the teeth possess the greatest power of re 
ance to deleterious agencies. This resisting power is, 
at best, comparatively feeble ; but its feebleness is, to 
some extent, compensated by the peculiar structure 
of the teeth, which is less liable to decomposition 
than any other part of the human body. Yet the 
integrity of these organs depends much on the main- 
tenance of a healthy vitality, and this on that of the 
general system. A dead tooth will decay far more 
rapidly than a living one in similar circumstances ; 



CAUSES OF CARIES. 53 

and hence the conclusion that vitality resists inju- 
rious agents, and that the resistance will be propor- 
tionate to the vitality. 

All febrile conditions promote and facilitate decay, 
and frequently in two ways : by diminishing the 
general vitality, and by changing the secretions of 
the mouth so that these act injuriously upon the 
teeth. Accompanying such conditions, there is gene- 
rally inflammation of the dentine ; and in such cases, 
this always partakes of the general disorder so as to 
become very susceptible to injury. All diseases, 
indeed, that impair the vitality and change the secre- 
tions, may be considered predisposing causes of decay, 
and some even more; dyspepsia, for instance, being 
not only predisposing, but also exciting, since it pre- 
pares in the stomach an acid that is almost continu- 
ally thrown upon the teeth, and that acts upon them 
with great energy. Eesidence in miasmatic regions, 
is also a predisposing cause, inducing unfavorable 
conditions. 

Diminished vitality may result either from consti- 
tutional or from local causes. These latter are such 
as produce an irritable or diseased condition of the 
immediate parts, or an abnormal condition of the 
dentine, without the power to effect its decomposi- 
tion. Local causes of a diminution of vitality are 
not in their character so formidable, and not so diffi- 
cult to control, as those which are constitutional. 



54 CARIES OF THE TEETH. 

Many medicinal agents are regarded as predis- 
posing causes of caries ; and among these, mercurials 
occupy a prominent place. They operate by vitiating 
the secretions of the mouth, and producing an abnor- 
mal condition of the periosteum about the fangs of 
teeth, the mucous follicles, and the salivary glands. 
Some entertain the opinion that the abnormal action 
of the absorbents, induced by mercurials, predisposes 
to decay. 

Dental operations performed at an improper time 
and in an improper manner, may be reckoned among 
the predisposing causes of caries. The vitality of the 
teeth may be thus impaired, or a diseased condition 
established, or the part operated upon may be per- 
mitted to remain rough, so that foreign substances 
will be retained, and, becoming vitiated, produce a 
deleterious effect. Often, from an improper use of 
the file, extensive inflammation of the dentine super- 
venes, which is sometimes followed by death of the 
tooth, and by disease of the contiguous parts. Arti- 
ficial substitutes imperfectly adapted, are, in many 
instances, the occasion of caries ; not that clasps or 
the edges of the plate tend directly to injure the 
tooth, but the agencies superinduced by them do, 
and especially when the material used is not of the 
right quality. 

Lack of proper exercise in mastication induce 
condition that is favorable to decay. It does so. 



EXCITING CAUSES OF CARIES. 55 

however, rather by favoring injurious agents to act 
on the teeth, than by imparting any direct predispo- 
sition to the teeth themselves. Substances of all 
kinds are deposited much more rapidly when the 
teeth are idle. 

The teeth cannot, with impunity, undergo sudden 
transitions from one extreme of temperature to 
another, or even such extremes as may be endured 
by the surrounding parts. By these, inflammation of 
the dentine may be induced, and the vitality of the 
teeth diminished, so that, even in friable teeth, 
checking of the enamel will occur, and thus a condi- 
tion arise that will facilitate decay. 

EXCITING CAUSES OF CARIES. 

When there is a predisposition to caries, any of the 
exciting causes act with more vigor. Teeth that are 
well constituted, and that have retained unimpaired 
health and vitality, withstand influences that, in less 
favorable circumstances, destroy them in a very short 
time. The immediate cause of decay is the action of 
agents chemically upon the teeth. It is not here 
proposed to enter upon an investigation of the man- 
ner in which these various agents operate ; for that 
would open up a vast field for exploration — a field 
outside of the province of this work. The sources of 
these agents, however, are several : as, vitiated secre- 



56 CARIES OF THE TEETH. 

tions of the mouth, the saliva, and the mucus; abnor- 
mal secretion from the stomach ; decomposition of 
animal and vegetable substances in the mouth; acids 
taken with food, or administered as medicines ; and 
galvanic action. 

Sometimes the secretions of the mouth are wholly 
acid, and thus these natural products, so vitiated, be- 
come instruments of mischief. The natural state of 
the mucus is acid, but that of the saliva alkaline ; 
so that these secretions counteract each. other; but 
when the saliva and the mucus are both acid, the 
teeth must suffer. These secretions may become 
vitiated, through inability of the glands, from disease 
or an enfeebled condition, perfectly to perform their 
functions ; or the blood may be in an abnormal state, 
and the glands unable, on that account, though they 
were healthy, as they seldom are in such case, to 
elaborate healthy saliva: when the fountain is cor- 
rupt, the stream cannot be pure. Thus, anything 
that produces a diseased condition of the blood, tends 
to the decay of the teeth ; and such diseased condi- 
tion often has a direct injurious effect on the secre- 
tive apparatus, and so works a double harm. 

But to the theory of the pernicious influence of the 
saliva, it may be objected, that, if it were true, all 
parts of the teeth would be alike affected. This 
objection, however, will lose its force when it is con- 
sidered that the teeth, in many cases, are not equally 



EXCITINa CAUSES OF CARIES. 57 

well organized in all their parts ; that some parts are 
not so well protected as others ; and that between the 
teeth there is room for the retention of saliva and 
foreign substances, which there combine their influ- 
ence upon them. In cases in which there is a great 
quantity of viscid saliva constantly flowing, the teeth 
decay very rapidly. The decay is of a light color ; 
so light, indeed, that, in many instances, it is difficult 
to distinguish it, by this, from undecomposed dentine. 

The gastric fluid often becomes deranged by irrita- 
tion or disease of the stomach, so that the function 
of the latter is very imperfectly performed, and fer- 
mentation of the food occurs, evolving agents that 
injuriously affect the teeth. In dyspepsia, such 
agents are often brought in contact with the teeth by 
eructation and vomiting; and the diseased gastric 
fluid, which contains a large proportion of hydro- 
chloric acid, is also thus brought in contact with 
them, acting upon them with great violence. After 
food commingled with this secretion is ejected from 
the stomach, the teeth will be found eroded over all 
their surfaces. Dyspeptics will appreciate this re- 
mark. In such cases, if the teeth are not of superior 
organization, they are destroyed in a short time. 
Their surfaces thus roughened, afford a lodgment for 
foreign substances on all parts. 

The most common agents, however, that injure the 
teeth, are originated in the mouth, by the decompo- 



58 CARIES OF THE TEETH. 

sition of animal and vegetable matter. By this pro- 
cess,- elements are eliminated, that form new combi- 
nations, and these operate as refined instruments in 
the destruction of the teeth. Favorable conditions 
exist in the mouth for such decomposition, and also 
for such new combinations ; for there is a sufficient 
amount of heat and moisture ; and both of these, 
especially the former, facilitate the action of any acid 
upon the dentine. The character of the saliva and 
mucus will very much modify the decomposition of 
foreign substances in the mouth. If these secretions 
are both acid, the decomposition will be much more 
rapid, and more potent in its effect. 

Again, it is sometimes the case that the salivary 
glands are comparatively inactive, except when spe- 
cially excited, and yet the mucous glands still effi- 
cient, eliminating their secretion ; so that the mouth 
assumes an acid condition, because there is not saliva 
sufficient to neutralize the mucus; in which condition 
decomposition of foreign substances would be greatly 
accelerated. There are many cases, however, in 
which the flow of saliva is copious, and yet the decay 
very rapid ; which is in consequence of an acid con- 
dition of both secretions, or of a rapid decomposition 
of foreign substances in the mouth. 

There are acids taken with the food that act di- 
rectly upon the teeth ; as acetic acid, or vinegar. 
Professor Westcot says : f Acetic and citric acids so 



EXCITING CAUSES OF CARIES. 59 

corroded the enamel in fortyeight hours, that much 
of it was easily removed with the fingernail." And 
" Malic acid, or the acid of apples, in its concentrated 
state, also acts promptly upon the teeth." Now r , 
these acids, in the use of many kinds of food, are 
brought into frequent contact with the teeth. In 
the manufacture of vinegar, sulphuric acid is often 
employed; so that in this article of food we have 
that acid either alone or combined with the acetic, 
the former acting with greater energy upon the teeth 
than the latter. Acetic acid also facilitates the de- 
composition of food retained in the mouth, and thus 
reproduces itself in abundance. 

After eating apples that contain a great amount of 
malic acid, the teeth will be found corroded over all 
their surfaces. This acid, as well as the others, af- 
fects the enamel somew r hat, and when the latter is 
very thin, though it may not be all removed from 
any particular point, yet its integrity will be de- 
stroyed, so as to be readily fractured, thus admitting 
injurious agents in contact with the dentine, which is 
much more susceptible of injury from acids than the 
enamel : points imperfectly protected by this are vio- 
lently attacked by acetic, malic, and sulphuric acids. 
In decayed cavities these agents produce rapid re- 
sults. They should be as much as possible avoided, 
and, when necessarily used, should be removed from 
the teeth by cleaning with great care. It would be 



60 



CARIES OF THE TEETH. 



safest to employ some neutralizing agent after the 
use ' of any acids with food. During mastication, 
there is an increased secretion of saliva, which, if in 
a healthy state, will tend to neutralize any acid that 
may at the time be present, and also, by its flow, to 
remove foreign substances from the mouth. 

Salts may be decomposed in the mouth, and their 
acids act upon the teeth; as when the acid of the salt 
has a stronger affinity for any element of the tooth- 
bone than for the base with which it is combined. 
Many medical preparations contain agents peculiarly 
deleterious to the teeth ; acids being especially in 
requisition for these, and not in homeopathic dilu- 
tions, either. The acids most commonly thus admi- 
nistered are the hydrochloric, the nitric, the sulphu- 
ric, the acetic, the tartaric, and the citric, any one of 
which will produce direct and rapid decomposition of 
the dentine, even when unaided by the temperature 
of the mouth. These acids are often administered 
by physicians, without any regard to their nature or 
their influence upon the teeth. Sometimes, however, 
they are given through a tube; though this method 
generally does not amount to much as a precau- 
tionary measure, for in most instances the fluid comes 
in contact with all parts of the mouth. A subse- 
quent rinsing of the mouth with water effects only a 
dilution, not an entire removal of the acid. In order 
wholly to counteract their injurious influence upon 



EXCITING CAUSES OF CARIES. 61 

the teeth, an alkaline solution should be used after 
the administration of such medicines. 

Galvanic action is a cause of decay of the teeth, 
only so far as it is a means of decomposing com- 
pounds which are in the mouth, and the elements of 
which, according to the laws of affinity, form other 
compounds, some of which are highly prejudicial to 
the teeth. The elements hydrogen, nitrogen, and 
oxygen, may thus be set free from animal and vege- 
table substances, when they will at once seek other 
elements with which to combine ; and the character 
of the combinations will be determined by the nature 
of the elements, and by the attendant circumstances. 
These compounds will frequently be of an acid char- 
acter. 

Such an arrangement may exist as will maintain a 
constant galvanic action, whose legitimate effects will 
be as constant upon the teeth; and this ceaseless 
process cannot but make its mark. It is a favorable 
arrangement for galvanic action when there are two 
or three kinds of metals in the mouth at once, par- 
ticularly if these are such as differ in their affinities 
for oxygen. In some cases three or four kinds of 
metals are employed in rilling teeth of the same 
mouth ; in some, fillings of one metal and a plate of 
another ; and in others, plates of so few carats are 
used that they oxydize rapidly in the mouth, without 
the aid of any other metal. 



62 



CARIES OF THE TEETH. 



COMPARATIVE LIABILITY TO DECAY. 



All classes of teeth are not alike liable to decay. 
Their difference in this respect may arise from a dis- 
similarity in their organic structure, the best organized 
being the most capable of resisting disease; or from a 
concentration of the destructive agency upon the 
tooth first affected. The first molars are much more 
liable to decay than any other teeth, since they are 
less perfectly developed than those formed at a later 
period of life. They are the first permanent teeth 
irrupted, and are subjected to all the irritating con- 
ditions consequent on the removal of the temporary, 
and the irruption of the other permanent teeth. But 
these conditions, in many cases, produce no apparent 
injury upon them, they maintaining their integrity 
till all the other permanent teeth are irrupted, and 
then decaying earlier than any others. In such 
cases, the decay is a result of influences more efficient 
than those occurring on the irruption of the other 
teeth. 

After the first, the second molars are most subject 
to caries ; and after these the second bicuspids. The 
latter two classes doubtless are so subject, more from 
the facility they afford to the lodgment of deleterious 
substances, than from a relatively imperfect organiza- 
tion. Besides, from six to fifteen years of age, the 



COMPARATIVE LIABILITY TO DECAY. 63 

teeth are less appreciated and less cared for than at 
a later period of life. The next most liable to decay 
are the third molars. Then follow in order the first 
bicuspids, the lateral incisors, the central incisors, and 
the cuspids. Below are appended, in tabular form, 
one thousand cases of decayed teeth, as observed 
under ordinary circumstances, exhibiting the number 
and per cent, of these in each class : — 

26, or 2J per cent., in central incisors. 



38, or 3f 


u 


in lateral incisors. 


24, or 2± 


u 


in canines. 


87, or 8| 


a 


in first bicuspids. 


134, or 13| 


u 


in second bicuspids 


370, or 37 


it 


in first molars. 


218, or 22f 


a 


in second molars. 


102, or 10J 


u 


in third molars. 



Of these, a large proportion were removed for relief 
from disease originating in caries of the dental tissue. 
In general, the superior teeth are liable to decay 
earlier and more rapidly than the inferior. 



CONSEQUENCES OF CARIES. 



It is here proposed to refer only to some of the 
more common results of this affection, one of the 
most obvious of which is the exposure of the pulp of 
the tooth; on which exposure, disease ensues, and 



64 



CARIES OF THE TEETH. 



finally death. During this diseased condition of the 
pulp, there occurs that very peculiar sensation com- 
monly denominated toothache. As well as the 
destruction of the pulp, the entire destruction of the 
crown of the tooth is the inevitable consequence of 
caries, unless this is interrupted in its progress. 
After the destruction of the pulp and the lining 
membrane, the external periosteum in many cases 
becomes involved, the affection being but an exten- 
sion of that which destroyed the internal. periosteum. 
Inflammation and suppuration are of common occur- 
rence, by which a discharge is established from be- 
tween the margin of the gum and the neck of the 
tooth, or through a fistulous opening in the process 
and the gum, as is the case when an abscess is formed 
at the point of a root. 

A diseased condition of the alveolar process is. in 
many instances, produced by diseased and dead teeth ; 
necrosis and an exfoliation of considerable portions 
being sometimes the effect. Indeed, extensive caries 
of the jaw is occasionally thus produced. Disease of 
the antrum, too, is very generally induced or greatly 
aggravated by the same cause. Tumors, sometimes 
of a malignant character, connected either with the 
bony or with the soft parts, not unfrequently spring 
from this source, particularly in constitutions of a 
cancerous diathesis. Great nervous derangement 
may result, either in whole or in part, from decayed 



CONSEQUENCES OF CARIES. 65 

teeth, as does very frequently facial neuralgia, which 
is sometimes confined to a single nerve-branch in the 
immediate vicinity of the irritating cause, sometimes 
ramified over the whole side of the face and head, 
and occasionally spread much farther, so as even to 
implicate the shoulder and the arm. Neuralgia of 
these, extending down to the hand, is often found to 
be instantly relieved by extraction of a diseased 
tooth ; and any operator of much observation can 
call to mind numerous instances in which facial neu- 
ralgia has been thus relieved or wholly cured. This 
affection of the face, however, does not always origi- 
nate in diseased teeth ; though there is little doubt 
that, in a majority of cases, it rises wholly or par- 
tially from this cause. 

Inflammation of the mucous membrane of the 
mouth, is a common result of diseased teeth ; and it is 
liable to extend to distant parts of this membrane, 
and occasion greater difficulty than in the mouth, as 
would especially be the case when there is an irri- 
table condition of the throat and bronchia; and the 
esophagus and stomach would not be exempt. In 
what degree such an implication of the respiratory 
and the digestive apparatus is referable to diseased 
teeth, it may not be easy to determine; but it is 
impossible that a number, of such teeth, involving in 
their disease all the ramifications of the facial nerves 
and the whole mucous membrane of the mouth, could 



66 



CARIES OF THE TEETH. 



remain there with impunity. And besides this direct 
influence on the lungs and stomach, diseased teeth 
are constantly emitting offensive odors, which are 
taken in by inhalation, and offensive matter, which is 
swallowed with the food. 

TREATMENT OF CARIES. 



In the rational treatment of caries, the first con- 
siderations are the nature and peculiarities of the 
obvious predisposing causes ; whether these are con- 
stitutional or local; and if constitutional, whether 
they are such as can be modified by therapeutic 
treatment of the general system. If the latter, such 
treatment should be adopted as will bring about the 
most perfect state of health, so as to obviate as fir ia 
possible all conditions favorable to decay, by securing 
a healthy state of the mouth in all its parts — as the 
gums, the mucous membrane, the salivary glands. 
The teeth should be kept free from all deposits and 
accumulations of whatever character; for. though 
some of these may not affect the teeth directly, yet 
they induce disease of the surrounding parts, and 
thus indirectly exert a pernicious influence upon 
them. 

The foregoing remarks, .however, refer rather to 
the prevention of decay than to its treatment after it 
actuallv exists. Yet thev are. on that account, none 



TREATMENT OF CARIES. 67 

the less important, since here, as elsewhere, preven- 
tion is better than remedy. But they apply to such 
prevention as well after decay has commenced as 
before, if the ultimate object is a preservation of the 
teeth. After the first attack, the teeth are always 
more vulnerable, and less capable of resistance. 

When decay has attacked a tooth, the treatment 
depends upon the nature and extent of the disease. 
Rapid decay requires more prompt and energetic 
treatment than that of slow progress. Remedies 
that would be appropriate and efficient in the one, 
would be quite inapplicable to the other. The per- 
sistence of caries is not always in proportion to its 
rate of progress. We sometimes find teeth in which 
the decay is not advancing rapidly, and thence are 
led to conclude that it may be easily arrested ; the 
affected part, if superficial, is removed, and the den- 
tine finely polished ; and yet, after a time, decay 
again attacks the tooth at the same point. Or, where 
the caries has penetrated the tooth, so that it re- 
quires filling, though it is skillfully filled, and the 
plug and tooth carefully polished, yet in many in- 
stances the dentine soon softens about the border of 
the plug. 

The extent of the decay will suggest the mode of 
treatment. Superficial caries on some parts of the 
teeth may be remedied and removed by cutting away 
the portion implicated in the disease, dressing with a 






68 CARIES OF THE TEETH. 

fine file, polishing with Arkansas, Scotch, or rotten 
stone till the filemarks disappear, and then applying 
the burnisher very thoroughly to the entire surface 
operated upon. Afterward, the most careful atten- 
tion to cleanliness is requisite, to prevent a recur- 
rence of the attack. This treatment is applicable to 
decay upon proximal surfaces ; but in the depressions 
of the masticatory or buccal surfaces of the molars, 
and on the labial surfaces of the front teeth, it can 
not be employed. 

Sometimes the dentine, at points where it is ex- 
posed, gives warning, by acute sensitiveness, of 
threatened decomposition, before there are any other 
indications of it, thus evidencing the presence of 
some very irritating agency promotive of decay. 
Such points should receive prompt and strict atten- 
tion, and the increased sensitiveness be immediately 
subdued ; as it may be, by the use of some prepara- 
tion that will counteract the exciting influence — some 
dentifrice or lotion containing an alkali; or a rubbing 
of the sensitive surface with a smooth steel burnisher, 
will in many cases effect this object, and prevent the 
development of decay. 

It has been suggested that the character of the 
caries may be modified by the local application of 
therapeutic agents — that the rapid decay may be 
changed to the slow — and this, too, without regard 
to the attendant circumstances, such as the condition 



TREATMENT OF CARIES. 69 

of the secretions of the mouth, the causes producing 
the disease, etc. ; and various such agents have been 
proposed. It is held that by an application of the 
nitrate of silver, the white, rapid decay being changed 
to that of a dark color, becomes of less rapid progress. 
But there is no very palpable principle on which this 
agent can be supposed to operate to arrest caries. It 
is generally conceded to be injurious to a healthy 
tooth ; how, then, it becomes beneficial to one 
decayed, it is not easy to perceive. The notion may 
have originated in the fact that, after the application 
of nitrate of silver, the cavity turns dark, or black ; 
and this color being naturally associated with the 
slow form of decay, it may have been concluded that 
it might be thus associated by artificial means. This 
conclusion, however, is fallacious; for the coloring 
matter being the oxyd of silver deposited on the 
walls of the cavity, is wholly foreign, and holds no 
necessary relation to the kind of decay, or to the 
agency producing it. The deposit may possibly serve 
as a temporary shield to the dentine beneath, but 
only temporary ; whereas, on the other hand, it will 
be remembered that nitric acid is liberated by the 
decomposition of the nitrate, and operates destruc- 
tively upon the tooth-bone. An ethereal solution of 
the terchlorid of gold has also been suggested as a 
preventive application. Its operation would be much 
the same as that of the nitrate of silver, and equally 



70 CARIES OF THE TEETH. 

inefficient. Preparations to neutralize and counteract 
the e'ffects of deleterious agents upon the teeth have 
been recommended as topical applications. These 
are such as possess alkaline properties. But anything 
of this kind would require frequent application ; in- 
deed, it would be necessary to keep the affected part 
constantly under its influence, as long as the sur- 
rounding conditions continued to favor decay. 

Though nothing of this kind can be relied upon 
permanently to arrest caries, yet, in many instances, 
much benefit is to be derived from local treatment. 
Alkaline topical applications will, in many cases, 
alleviate the most acute sensitiveness of the dentine; 
accomplishing this, no doubt, by their neutralizing 
influence upon the irritating agents. Many opera- 
tors employ simply the bicarbonate of soda for this 
purpose, with the happiest results. As an other class 
of topical applications to check or modify caries, 
those have been suggested, which will form an insol- 
uble compound with the gelatinous or animal portion 
of the tooth ; such as tannin and some of the essen- 
tial oils. The only effect of these, however, is, to 
form a shield or protection over the structure be- 
neath : there is, of course, no change effected in the 
conditions or agencies which produce the decay. 



CHAPTER III. 

GENERAL REMARKS ON FILLING. 

The importance and value of the operation of fill- 
ing are obvious, from various considerations. It is 
one that is in frequent requisition. It is the only 
treatment for deepseated caries : by it, the disease is 
arrested and the lost part restored, so far, at least, as 
it can be by a foreign substance. There is no mate- 
rial similar to that destroyed — no substance possess- 
ing the characteristics of the lost portion of the tooth 
—with which to effect the restoration. Under favor- 
able circumstances, the operation of filling is efficient 
in arresting caries and restoring the lost portion of 
the tooth. In order, however, that it be permanent 
in its character, the case needs to be attended with 
favorable conditions, and the work to be thoroughly 
done. But, two similar operations, both equally well 
performed, may result very differently as to ultimate 
success in preserving the teeth to which they may 
have been applied; the one effectually preventing 
further decay, and the other seeming to interpose to 



72 GENERAL REMARKS ON FILLING. 

it but little obstacle. Indeed, the probabilities of 
such' success in different operations, equally well ac- 
complished, cannot be calculated, without consider- 
ing a variety of circumstances, such as differences in 
constitutions, in states of health, in previous and sub- 
sequent habits. 

The filling of the teeth is predicated upon the na- 
ture of decay, upon the fact that the lost portion will 
not be restored by nature, and upon the fact that 
caries is an effect of external causes, and not of any 
cause within the tooth itself. If the cause of caries 
were alone within the tooth itself, then filling would 
not be its rational treatment. The organic structure 
of the teeth is of such nature that no change will 
take place in it, independently of external influences. 
Any organ possessing sufficient vitality and circula- 
tion to be susceptible of disease and decomposition, 
independently of external influences, possesses recu- 
perative power enough to restore to itself a lost part; 
and if dentine could be decomposed without external 
agents, the introduction of any foreign substance 
whatever into 'the cavity, would certainly not arrest 
the decay, but most probably would accelerate it. If 
it is true that decay of the teeth ever originates in 
constitutional causes, then the treatment should be 
constitutional, and not local. 

The filling of teeth, then, is based upon the ina- 
bility even of healthy dentine to resist the encroach- 



GENERAL REMARKS ON FILLING. 73 

inent of decay. As preliminary to the operation, all 
the circumstances, both direct and collateral, should 
be carefully noted in every case, and the course of 
treatment should conform to the indications thus ob- 
served. The constitution, temperament, and health 
of the patient ; the peculiarities of the teeth ; their 
susceptibility of decay ; their present condition, and 
that of the parts about them; the periosteum, the 
gums, the mucous membrane, the secretions of the 
mouth, the saliva, and the mucus, should all be 
closely considered; for only on a correct diagnosis 
can a proper treatment be based. Every operation 
should be performed as completely as, under the cir- 
cumstances, is possible. Indeed, every step in the 
operation should be perfect, before a successive one is 
attempted. All the instruments employed should be 
unexceptionable in material, form, and condition; 
inferior instruments should find no place in the case 
of the dental operator. The material for filling 
should be of the best quality, and prepared in the 
best possible manner. Not that material for filling 
should be prepared in only one way; for some mate- 
rials, gold for instance, may be prepared in three or 
four different forms, each perfect in its kind, and effi- 
cient in the hands of the expert manipulator. "While 
with instruments and material all in the most perfect 
condition, and with a thorough cognizance and appre- 
ciation of all the attendant circumstances, our most 



74 



GENERAL REMARKS ON FILLING. 



skilful operators barely attain success, need we be 
astonished that the man ignorant of all these circum- 
stances, and possessed of only a few crude, ill-condi- 
tioned instruments and materials, the nature of 
which he does not understand, fails in almost every 
essay ? 

Much depends on therapeutic treatment; not, in- 
deed, to restore parts already lost, or to restore to 
health parts much diseased, but to avert a tendency 
to disease in parts but feebly organized. -This treat- 
ment may be either constitutional or local, or both ; 
but constitutional when there is indicated any 
idiosyncrasy favorable to decay. If, however, the 
whole difficulty is local, topical treatment only is re- 
quired. What the special treatment should be in 
either case will be more fully considered hereafter. 
Comparatively little can be accomplished by local ap- 
plication to the substance of the tooth ; but the parts 
contiguous, as the gums and the mucous membrane, 
may be thus treated, with an assurance of more 
signal results. 

Though in the teeth nature does not assist to re- 
store a lost portion, as in those parts more highly 
organized, yet, to compensate in some degree, the de- 
structive process is far less rapid in the former than 
in the latter. The general surgeon depends much 
upon nature for the success of his operations; for, 
though he perform them unskilfully, yet the kind 



MATERIALS FOR FILLING. 75 

energy of nature is always present to assist him ; but 
in this specialty the practitioner must necessarily de- 
pend more upon his skill, and less upon the curative 
efforts of nature. 



MATERIALS FOR FILLING. 

In the selection of materials for filling teeth, there 
are some important considerations that should be 
kept constantly in view ; the first and principal of 
which is to choose that kind which will protect the 
tooth from further decay — protect the affected part 
against the influence of those agencies on which the 
disease depends. A material or class of materials 
should be selected that would not, under any circum- 
stances, operate either as a local or a constitutional 
injury. There are several properties that materials 
for filling teeth should possess, one of the most im- 
portant of which is indestructibility. This term is 
technically applicable only to compounds; but we 
venture here to expand its sense so as to indicate by 
it an integrity of substance as well in a simple as in a 
compound material ; for, considered with reference to 
the purpose of filling, a combination of the simple 
with another substance, is as much a destruction as is 
a decomposition of the compound. Any substance, 
whether simple or compound, that will not maintain 
its identity and integrity when subjected to any con- 



76 GENERAL REMARKS ON FILLING. 

ditions of the mouth, is wholly unfit to use as a ma- 
terial for filling. If compounds are emplo} 7 ed, they 
should be such as would not be affected by the secre- 
tions of the mouth, by its temperature, or by its con- 
ditions. A mere mechanical mixture would not be 
an appropriate material; and all compounds of the 
metals, so far as we are familiar with them, are unfit 
for this purpose, by reason of the facility with which 
they are destroyed in the mouth. 

The next most important property of' a material 
for filling, is, adaptability ; by which is meant a capa- 
bility of being wrought into suitable shapes for the 
purpose, — a facility of being applied and conformed 
to the parts upon which it is to be placed. There 
are substances that would be entirely indestructible 
in the mouth, and that would be very desirable in 
other respects as materials for filling, yet that are 
altogether worthless for this purpose, from lack of 
adaptability. Quartz, if it possessed this property, 
would be valuable as a material ; but as yet there 
has been discovered no method of preparing it in an 
available form. On the other hand, many things 
possess the property of adaptability, that are lacking 
in some other important particulars. 

The next important property is, hardness. A 
material may possess all the other suitable qualities, 
and yet be too soft. A material should be hard 
enough not to be broken by any pressure or friction 



xMATEKIALS FOR FILLING. 77 

liable to be applied. This property is especially desi- 
rable for fillings in the masticatory surfaces of the 
molars and bicuspids. It would, however, be admis- 
sible to employ a softer material for filling cavities in 
the proximal surfaces of the teeth, provided it per- 
fectly excluded all foreign substances. 

Again, a material should be as nearly as possible a 
nonconductor of heat, particularly for filling sensi- 
tive teeth, or those liable to become so under the 
influence of slight causes. Extreme variations of 
temperature will, in most instances, aggravate sensi- 
tiveness, and, in susceptible cases, produce it; and, if 
the irritation is continued, the result may be necrosis. 
Gold, which possesses the largest number of desirable 
qualities as a material for filling, is in this respect 
very defective, being one of the best conductors of 
heat. To obviate this defect, some nonconducting 
material is employed between the gold and the sensi- 
tive portion of the tooth. The nerve is liable to be 
affected by sudden and extreme changes of tempera- 
ture, transmitted to it through a gold plug. 

In the next place, a material should be susceptible 
of being welded, or united into a solid mass. The 
permanency of an operation depends very much 
upon this quality. A filling having the different 
pieces which compose it perfectly consolidated, will 
be much more durable than if effected with a mate- 
rial in which this cohesive property is lacking, can 



78 GENERAL REMARKS ON FILLING. 

be made with greater facility, and will be better and 
longer retained; and mainly because such a filling 
cannot be destroyed piecemeal. Noncohesive mate- 
rial is retained by the general form of the cavity, 
which is to be shaped so as to bind all the pieces 
together, and thus hold them in place ; but a sub- 
stance that will weld, requires only two or three 
good retaining points, angles, or pits, properly situ- 
ated, in order to be firmly and permanently fixed 
in a cavity of any form. 

Color. — An other desirable property of a material 
for filling, is, such a color as shall best harmonize 
with that of the teeth, particularly if they are in 
front. In this respect, all the metals are objection- 
able; though gold is probably less so than any of the 
others, the objection to this being not so much in its 
color as in its luster; which objection, however, may 
be partially obviated by the kind of finish given to 
the work. In teeth of certain shades — semitrans- 
parent bluish white, for instance — gold, for exposed 
fillings, is very objectionable ; indeed, in some cases, 
as unsightiv as would be an entire absence of the 
tooth ; and, in such instances, the darker metals 
would of course appear much worse. For such teeth, 
some mineral substances would be most desirable. 

Most of the materials employed for filling are 
metallic; only a few nonmetallic substances have 
been used, and these rather by way of experiment, 



MATERIALS FOR FILLING. 79 

than with any hope of permanent success. Of the 
metals, gold possesses more of the indispensable pro- 
perties than any other ; but the following have all 
been used for filling : lead, tin, silver, platinum, gold, 
and amalgam. In the preparation of the latter, 
gold, silver, platinum, tin, bismuth, antimony, cad- 
mium, zinc, and mercury, have been employed. 

Lead. — This metal, in the early history of the pro- 
fession, was used to some extent for filling, though it 
possesses but few of the requisites for that purpose. 
The principal quality which recommended it, is its 
adaptability ; but it is quite too soft for permanent 
fillings in the masticatory surfaces of the molars. It 
is easily wrought into foil and welded into mass in 
the cavity, but is rapidly worn down by mastication, 
and its integrity readily impaired by the influence of 
peculiar conditions of the mouth ; much more readily, 
indeed, than that of tin or silver. Acetic and other 
acids act upon it with considerable energy in the 
mouth, being there subjected to both heat and moist- 
ure. By exposure to air and moisture, it is soon 
coated with carbonate or protoxyd of lead ; and this 
change is effected much more readily in the mouth. 
Lead is also objectionable in color — especially for fill- 
ing's in the anterior teeth — it being darker than the 
other metals employed for the purpose. It is, how- 
ever, a less perfect conductor of heat than some 
others that are in far more extensive use. 






80 



GENERAL REMARKS ON FILLING, 



Tin. — This metal has been, and is even vet, much 
employed as a material for filling. It is easily 
wrought into foil, and in that condition is readily 
adapted to the purpose, by reason of its softness and 
pliability. Fillings cajj^ be made with it in all cases 
in which nonadhesive gold foil can be used, to much 
of which, indeed, it can, by skillful manipulation, be 
made superior in adhesive property. Its quality, 
however, is greatly dependent on the manner of its 
manufacture. It is harder than lead, and in many 
cases hard enough for permanent fillings : we have 
known it retained in crown cavities of the molars, 
effectually preserving the teeth, for fifteen years. In 
favorable conditions of the mouth, it is not materially 
changed, not oxydizing easily, and not readily uniting 
with any substances liable to be brought in contact 
with it. But in an unhealthy mouth, with the secre- 
tions in an abnormal condition, and the teeth 
neglected, tin fillings are very rapidly destroyed. 
Such a change may take place in the mouth, as will 
in a little time destroy tin fillings that had long 
remained in good preservation ; and hence this mate- 
rial is not entirely reliable in any case, since such 
change may at any time occur. Some cases seem- 
ingly favorable to its use, are found, on examination, 
to be otherwise ; and in almost any mouth in which 
there is a large proportion of muCus secreted, it can 
not be depended upon for permanency. Its color 



MATERIALS FOR FILLING. 81 

renders it unfit for the anterior teeth. It is a less 
perfect conductor of heat than gold ; on which ac- 
count it is frequently employed where the latter 
metal can* not be. It should not be used in a tooth in 
which there is an other metal ; notwithstanding some 
economical dentists do sometimes use it to fill the 
interior of large cavities, placing upon it a covering 
of gold. This method is objectionable in two parti- 
culars : first, the tin is softer than the gold, and 
under much pressure yields beneath it, so as to 
destroy the integrity of the filling ; and second, when 
the fluids of the mouth come in contact with the two 
metals, a chemical action is induced, by which the 
tin is rapidly oxydized. It is for this reason that no 
two metals should be applied to the same tooth ; as, 
for instance, tin for filling a tooth round which there is 
a gold clasp, or in contact with which is a gold plate. 
Finally, the use of this material should be deter- 
mined not only by all these circumstances, but also 
by the constitutional predisposition of the patient, 
and the character of the teeth, which should be dense 
and well organized, in order to render it at all admis- 
sible. 

Silver. — This metal was formerly in more extens- 
ive use as a material for filling, than it is at present. 
It is not, for this purpose, superior to tin in any par- 
ticular, except in being somewhat harder; and in 
some particulars it is inferior, being quite as de- 






82 GENERAL REMARKS OX FILLING. 

structible in the mouth ; more easily affected by cer- 
tain agents, such as nitric acid, nascent chlorine, etc.; 
less pliable and less adaptable ; more difficult to work 
into foil; not so readily formed into fillings; and pos- 
sessed of much less cohesiveness, being almost un- 
weldable by the ordinary method of manipulation. 
Silver is a better conductor than tin, and would 
therefore in some cases be more objectionable. The 
saliva is often in such a condition as to act upon it 
with great energy and rapidity. Its color, too, is ob- 
jectionable. With these disadvantages, its use has 
very properly been wholly abandoned. 

Platinum. — This metal has been but little used for 
the purpose of filling; though it possesses some of 
the requisite qualities in a very high degree ; as, for 
instance, indestructibility, in which property it is su- 
perior to gold. In some other respects, however, it 
is very deficient; it has not as yet been wrought into 
any form in which it can be welded with facility ; it 
is difficult to work into foil ; and, when it is put into 
this form, it possesses a stiffness and harshness that 
render its adaptation and condensation almost im- 
practicable. It is more on this account, perhaps, 
than on any other, that it has been so little employed 
for the purpose of filling. It has also less adhesive- 
ness than gold, and much sooner parts with this prop- 
erty. Slight crumpling or bending serves to stiffen 
it so as to destroy its applicability. Good fillings 



f 



MATERIALS FOR FILLING. 83 

may be made of well prepared platinum sponge, re- 
cently annealed. It requires skillful manipulation, 
however ; for the least moisture destroys its cohesive 
property entirely. It is quite as good a conductor of 
heat as gold, and on this account equally objectiona- 
ble. In the respect of color, too, it is undesirable. 
Platinum should never be placed in close proximity 
to tin fillings, or to gold plate or clasps of few carats. 
It is not now, however, used in filling at all, except 
for experiments. 

Gold. — Of all the metals that have as yet been 
used for filling teeth, gold possesses more of the 
requisite properties than any other. It is more inde- 
structible than any other, and sufficiently so for all 
practical purposes. Twenty-carat gold is very sel- 
dom affected by any agencies with which it is 
brought in contact in the mouth ; pure gold, never. 
In the filling of teeth, there are two objects to be 
aimed at : one, a sufficient hardness to withstand the 
wear of mastication ; the other, a thorough protection 
to the cavity against all foreign substances. For the 
attainment of the first of these, gold is not all that 
could be desired; yet it is, perhaps, as efficient in this 
respect as any other metal that can be employed. But 
the second object gold accomplishes perfectly; that is, 
so long as the filling maintains its integrity ; after it 
has partially worn out, it thus far fails, of course. In 
adaptability, too, gold is superior to any other metal. 



84 



GENERAL REMARKS ON FILLING. 



It can be elaborated into a variety of forms, with any 
of which very good fillings can be made. It can be 
perfectly conformed to any shape of surface, however 
irregular. A tooth that can be filled at all, can be 
filled with gold. This assertion was made a number 
of years ago ; and if it was true then, it is much more 
true now ; for then the adhesive property of gold was 
not employed at all, or even recognized as available ; 
but now, this property has been rendered efficient and 
practicable. Then, our best operators did • not aim to 
unite the different portions of gold of which the fill- 
ings were composed. The idea that such consolida- 
tion could be effected, seemed never to have entered 
their minds. Indeed, with the instruments and the 
method of manipulation then employed, this adhesive 
property could not have been made available ; but as 
it came to be recognized, the instruments and the 
manipulation were adapted to the purpose. For- 
merly, an ordinary gold plug when removed from a 
cavity, would be separated into as many pieces as 
originally composed it ; but now, when adhesive gold 
is skillfully used, the mass composing a filling can not 
be divided into its original parts, but may be wrought 
into plate, wire, or foil. Xonadhesive gold — the 
modification in which, till recently, it was always 
employed — would not weld, even under great press- 
ure ; but, in the mode in which it is now prepared, 
it will weld readily and thoroughly. There are cer- 



MATERIALS FOR FILLING. 85 

tain requisites essential to this welding property of 
gold : if it is in the form of foil, it must not present 
a smooth, planished surface ; it must be annealed 
after hammering, in order that its ultimate particles 
may be in the best condition for cohering; it must 
be entirely free from all deposits of foreign substance ; 
and it must be kept from exposure to the atmos- 
phere. 

Gold is a good conductor of heat; and this is the 

chief objection to it as a material for filling. As to 

< 

sensitive teeth, this is a very serious objection, in 
some cases necessitating the employment of non- 
conducting materials with it, and in others preclu- 
ding its use altogether. The color of gold, however, 
is seldom an objection to its use ; though it some- 
times renders it unsuitable for fillings in the front 
teeth. But this objection has been already adverted 
to. 

Various Preparations of Gold. — And first, of the 
manufacture of gold foil. For this purpose, pure 
gold is used; for procuring which, various methods 
are employed. But the most common of these are 
insufficient for the production of gold absolutely pure. 
It is, however, deemed irrelevant here to detail the 
process by which this end is attained : it is enough to 
premise that, for the manufacture of the best quality 
of foil, perfectly pure gold is indispensable. The 
gold is cast into an ingot about an inch wide, which 



86 GENERAL REMARKS ON FILLING. 

is placed between a pair of rollers, and rolled down 
as thin as practicable, the piece, while rolling, being 
frequently annealed. It is then cut into squares, 
which are inserted with wooden pliers between vel- 
lum leaves, a hundred and sixty or seventy in a 
pack. Over this pack two pockets are drawn, in- 
closing it completely. The pack then, while it is 
carefully annealed, is hammered on a marble block, 
with a hammer weighing twelve or sixteen pounds, 
till the leaves are spread out to the full extent of the 
pack. Much experience and skill are requisite to 
the proper accomplishment of this part of the work : 
by a single unskillful stroke of the hammer, a whole 
pack might be spoiled. 

Gold foil is numbered according to the grains con- 
tained in each leaf, ranging from 2 to 30. The most 
common numbers are, 2, 3, 4, 5, 6, 8, 10, 15, 20, and 
30, the smaller, from 2 to 6, being in most frequent 
use. It has heretofore been a desideratum to obtain 
gold foil perfectly uniform ; but some few manufac- 
turers now seem to have attained this perfection. 

Crystal Gold. — This form of gold was introduced to 
the profession about five years ago. Some experi- 
ments in this direction, indeed, had been made as 
early as 1825, by C. Ash, of London, and again in 
1850, by Dr. S. A. Main, of New York. Their prep- 
arations, however, were simply precipitates, and 
nothing more. But in 1853, Dr. A. J. Watts, of 



MATERIALS FOR FILLING. 87 

Utica, New York, obtained letters patent for his prep- 
aration of gold for filling teeth. This preparation 
was at first denominated sponge gold, but after some 
modification, received its present name. There are 
numerous formulas by which preparations of crystal 
gold may be made ; but so far as we are acquainted 
with them, they are all embraced in two general 
methods : the one, to obtain simply a precipitate of 
the metal, adaptable to the filling of the teeth ; and 
the other, to combine this precipitate with mercury, 
and obtain a definite crystallization. For the prepa- 
ration of the sponge or crystal gold, the absolutely 
pure metal is required. This is dissolved in nitro- 
muriatic acid, the gold being added till the solution 
is saturated. Various materials may be used to pre- 
cipitate it, the most common of which are sulphate of 
iron and oxalic acid, the latter on some accounts 
being preferable. The character of the precipitate 
will be determined, in a great degree, by the manner 
in which the precipitant is added : if slowly, the pre- 
cipitate will be more fibrous, or structural. 

A preparation may be made by introducing the 
precipitant gradually, and then carefully washing the 
precipitate, and heating almost to redness. For per- 
fect crystallization of the gold, combine the precipi- 
tate with from six to twelve times its weight of pure 
mercury, let it stand a short time, subject to a gentle 
heat, and then remove the mercury with dilute nitric 



88 GENERAL REMARKS ON FILLING. 

acid. Afterward wash the nitrate of mercury from 
the gold ; place the latter upon a slide, and bring it up 
to a full red heat in a muffle, and the gold is then in 
a condition to be used for filling. This is about the 
formula on w T hich a patent was granted to A. J. 
"Watts. The preparation possesses some advantages 
over gold foil : it is as readily introduced ; it is more 
capable of thorough consolidation ; it has, besides the 
cohesiveness of foil, the additional property of inter- 
lacing its crystals one with another, by which prop- 
erty, even without cohesion, the pieces of a filling 
can be firmly united ; and it takes a better hold 
upon the walls of the cavity, to which it presents 
edges and ends, so as to be more thoroughly adapted 
and fastened. 

Amalgam. — By this term are designated all those 
preparations formed by a combination of mercury 
with various other metals ; most frequently with sil- 
ver and tin, but occasionally with gold, platinum, 
bismuth, cadmium, zinc, and lead. The several form- 
ulas for amalgam need not here be specified. The 
kind most in use is prepared by melting together and 
carefully mixing pure tin and silver, filing this mixt- 
ure, when cooled, into dust, combining the latter 
with mercury in sufficient proportion to give the 
requisite plasticity, and then thoroughly washing the 
whole in alcohol or boiling water, to eliminate the 
oxyds formed by the combination of the metals. If 



MATERIALS FOR FILLING. 89 

there is a redundance of mercury, it may be removed 
by pressing the paste in a piece of chamois skin. 
This preparation may in some cases be used for 
filling with considerable success; but in no case can 
it be relied upon as a durable material, its destructi- 
bility being no less than that of tin or silver in any 
circumstances, and being greater where all the mer- 
cury is not removed from the surface of the filling, 
and the surface not burnished clown solid and 
smooth. Mercury oxydates with considerable rapid- 
ity when exposed to air and moisture, and with in- 
creased energy, under the influence of heat, especially 
when some acid is present. This facility of oxyda- 
tion is still increased when other metals are com- 
bined with the mercury. Oxydation of such fillings 
will in some cases be confined to the surface, wherever 
there is contact of moisture; in others, it will per- 
vade the whole mass, rendering it black and spongy 
throughout. 

Amalgam fillings, in a short time after their inser- 
tion, undergo a hardening process, caused mainly by 
evaporation of the mercury. The consequence is, 
either that the mass becomes porous, or that it con- 
tracts; the former, doubtless, in cases where the 
oxydation blackens through, and the latter, where it is 
confined to the surface. When a plug is in either of 
these conditions, the preservation of the tooth is very 
uncertain. On removing an ordinary amalgam plug 



90 GENERAL REMARKS ON FILLING. 

that has been worn for some time, its entire surface 
will generally be found oxydized : and a tooth filled 
with this material generally becomes blackened, and 
its appearance ruined. 

To such objections against this material, an other 
is to be added in cases in which there are fillings or 
plate of platinum or gold : galvanic action will be 
established, in a degree proportionate to the proxim- 
ity of the metals and the condition of the secre- 
tions. This may occasion much mischief. Some 
constitutions are very susceptible of the influence of 
mercury ; and a gradual decomposition of several 
amalgam fillings in the mouth, may seriously impair 
the general health. Therefore, before this material is 
ever employed, the health, temperament, habits of the 
patient, should be carefully noted ; for these and other 
circumstances may often indicate its inadmissibility. 

So great and so numerous are the objections to this 
material, that it is but little used by reliable oj 
tors. Its adaptability is the main property on which 
are based the arguments in its favor : it is easily 
applied, and consolidates with considerable hard: 
It is affirmed, also, that teeth which cannot be saved 
with anything else, may be filled with this, and made 
valuable. This, however, is not true since the em- 
ployment of the adhesive property of gold ; which 
property renders this metal equal in adaptability to 
amalgam. 



MATERIALS FOR FILLING. 91 

Nonmetallic Materials. — Of the nonmetallic mate- 
rials experimented with for filling, there are not 
many worthy of any particular consideration. In- 
deed, gutta percha and its preparations constitute the 
chief nonmetallic substances now used for this pur- 
pose, though some others have been employed. 
Gutta percha is useful for temporary fillings, and. 
under ordinary circumstances, sufficiently durable. 
It is valuable for filling those teeth which it may be 
desirable to retain only a short time, or those in 
which it may be necessary temporarily to protect a 
sensitive part against the influence of irritating 
agents, in order to restore it to health. Gutta 
percha is not readily decomposed by the fluids of the 
mouth, when they are in a healthy condition. In 
some instances, we have known it worn in the 
mouth for years, with but little change. But in 
cavities on the grinding surfaces of the molars and 
bicuspids, it will not withstand the wear of mastica- 
tion a great while, though long enough in most cases 
to subserve the purposes of a temporary filling. It 
possesses great adaptability : by simply being warmed 
over a spirit-lamp or in boiling water, it becomes 
plastic, and is with great facility introduced and con- 
formed to the cavity. It may be applied also in 
solution, being dissolved in chloroform till it ap- 
proaches a pasty consistence, then absorbed in a 
pledget of cotton, and introduced into the cavity; 



92 GENERAL REMARKS ON FILLING. 

where the chloroform, evaporating, leaves the gutta 
percha as a filling. The only objection to this 
method is, the contraction consequent on the evapo- 
ration of the chloroform. Another property that 
renders this substance highly valuable, is, its non- 
conduction of heat, it being in this respect as nearly 
perfect as any other material employed. 

A preparation of gutta percha with mineral sub- 
stances, known as HilVs stopping, has, for the last 
four years, been extensively used for temporary fill- 
ings ; indeed, it has superseded simple gutta percha 
almost entirely. The aim of this preparation was to 
obviate two or three objections to pure gutta percha ; 
as, its contractibility in the cavity, its softness, and its 
color. The composition of HtlTs stopping is as fol- 
lows : With pure gutta percha in a plastic state, are 
mixed quicklime two parts, and quartz and feldspar 
one part each, which latter are reduced to an impal- 
pable powder, and kneaded into the mass as long as 
it will receive them without becoming brittle. Such 
is the formula given by the inventor of this prepara- 
tion ; though it is presumed that one of these mate- 
rials alone, namely, pulverized quartz, would be 
found entirely sufficient, since it is capable, by itself. 
of quite as much as is attained by all together. The 
addition of gold or platinum filings has been recom- 
mended ; but no advantage is thus gained. It was at 
first claimed for this material that it would serve for 






MATERIALS FOR FILLING. 93 

permanent fillings ; but it was soon demonstrated in- 
sufficient. It was supposed, also, that it might be 
employed for partial fillings in large cavities, which 
could be completed with gold ; but for this, too, it 
was found impracticable, since it did not make a suf- 
ficiently firm foundation. 

This preparation is applied in the same manner as 
simple gutta percha, being warmed on a porcelain or 
metal slab over a spirit-lamp till sufficiently soft, and 
then packed into the cavity. It cannot be employed 
in the form of solution, nor should it be softened in 
boiling water. It may be conveniently prepared by 
dissolving the gutta percha in chloroform to almost 
a pasty consistence, then adding the mineral sub- 
stances, and putting it into a vessel suitable for the 
evaporation of the chloroform. It should be made so 
thick, that the silex would not fall to the bottom. 
When HilVs stopping or gutta percha is used, as soon 
as the cavity is filled, an instrument with the end 
nearly as large as the orifice of the cavity, should be 
placed upon the filling, and retained there with con- 
siderable pressure till the mass is cool. We as yet 
know of nothing better for temporary fillings than 
this preparation of gutta percha. 



CHAPTER IV. 

INSTRUMENTS FOR FILLING. 

In describing the instruments for filling teeth, it 
will be convenient to take them somewhat in the 
order in which they are employed in ordinary prac- 
tice ; first referring to those which are used for cut- 
ting away portions of the teeth, for the purpose of 
separating them, and for dressing off the borders of 
cavities; then to those for removing decay and form- 
ing the cavities; and finally to those for introducing, 
consolidating, and finishing fillings. The first, then, 
that claim our attention, are the 

HEAVY CUTTING-INSTRUMENTS. 

These are of the thick chisel shape. They should 
be of good steel, well wrought, and thoroughly tem- 
pered. Every step in the process of their manufac- 
ture should be most perfectly executed, so as to in- 
sure an edge that will cut not only dentine, but also 
enamel, which is the hardest animal substance. Va- 
rious sizes of the straight chisel form are required. 



HEAVY CUTTING-INSTRUMENTS. 



95 



In all cases they should be as thick as possible, with- 
out being thus impaired in their efficiency ; so firm 
that there may be no springing or tremulous motion 
under the pressure they are required to sustain. For 
separating front teeth, however, they must be thin 
enough to pass readily into the intended space, and 
about one fourth of an inch wide at the edge. (See 




Fig. 2.) But, for separating bicuspids and molars, 
the instruments should be thicker and broader; as 
thick, indeed, as the respective intervals will admit. 



Fig. 3. 




(Fig. 3.) In some cases, they should have the edge 
oblique, as in Fig. 4. 

It is seldom that these instruments need any 



Ficr. 4. 




curve. The straight form is the best, unless, as it 
rarely happens, the point to be operated upon can not 



96 



INSTRUMENTS FOR FILLING. 



be reached efficiently with it ; as, for instance, in a 
small mouth, a slight anterior curve will be required 
in the shaft of the instrument, to facilitate its ap- 
proach to the front proximal surface of a second or a 
third molar. (Fig. 5.) A heavy instrument, with a 



Fig. 5. 




sharp point and a lateral curve, is often efficient in 
opening up cavities and cutting down strong projec- 
tions of enamel. (Fig. 6.) This class of instruments 



Fi£. 6. 




we consider as valuable as any other in our case. 
Every operator should have at hand a sufficient va- 
riety to meet every demand. 



DRILLS, 



Bur Drills.— Of this indispensable class of instru- 
ments there are various forms. They should be 
manufactured of the best steel, and wrought with the 
greatest care. After having been forged as near the 



DRILLS. 



97 



proper size as possible, the bulb is shaped by dressing 
with a fine file, or by turning in a lathe; those 
made by the latter method being superior, and cut- 
ting much more smoothly ; they do not catch and jar 
as do those of less regular form. After the bulb is 
formed, it is usually cut with a sharp-edged file. 



Fiff. 7. 



Of these drills, Fig. 7 represents a bur of a spher- 
ical form. Fig. 8 is cone-shaped, which may have 

Fi°r. 8. 



various degrees of bevel, terminating in a sharp 
point. Fig. 9 is of a cylindrical form, cut upon 
the sides and end. Fig. 10 is in the form of a 



Fi". 9. 




wheel, cut upon the edge only, or upon both the 
edge and the end. The cutting upon all of these 



98 



INSTRUMENTS FOR FILLING. 



should be very regular and uniform. This should 
be made by machinery, though it is usually done by 
hand. Of these instruments, there should be a 



Fisr. 10. 




variety in size, the smallest considerably less than 
the smallest cavity the dentist ever attempts to fill — 
that is, about one thirtysecond of an inch in diam- 
eter, and the largest about one fifth of an inch. 
Inclusive of these extremes, there should be about 
fifteen sizes of each particular form. These instru- 
ments are used for opening cavities. With them a 
more regular and perfect orifice is made in small and 
medium-sized cavities, than by any other method. 
They are also used to some extent for forming the 
cavities, and even sometimes, in large cavities, for 
making retaining-points for a filling. 

Common Drills. — Of an other kind of drills, Fig. 
11 represents one with a square point, beveled from 

Fior. 11. 



both sides, measuring from a half to a whole line in 
length, and attached to a small round shaft. The 
edges of the drills should be very hard, so that they 



DRILLS. 



99 



may cut with the greatest celerity. Of this kind, 
there should be about ten sizes, ranging in width 
from No. 15 to No. 25 of Stub's gauge. These are 
used mainly for forming retaining-points in cavities. 
Fig. 12 is the spear-shaped drill, the edges of 

Fig. 12, 




which are formed by dressing from both sides ; or, it 
may be, from only one, in which case it will cut only 
when rotating one way. This shape is employed 
principally for drilling out fangs for filling or receiv- 
ing pivot teeth. 

The burs and drills may be made of pieces of wire 
one and a half inches long, and fitted to a socket- 
handle that will accommodate a large number ; or of 
a continuous piece of large wire. The latter is the 
preferable method, since much time is consumed in 
changing them in sockets. The handles should be 
made with six or eight sides, and cut on each alter- 
nate side. In the use of these instruments, the 
socket-ring is almost indispensable. This is an open 
ring for the middle or the index finger, with a socket 
attached, in which rests the end of the handle of the 



100 



INSTRUMENTS FOR FILLING. 



instrument. (Fig. 13.) The drill is rotated commonly 
with the thumb and ringers. 

Fig. 13. 




Drill-stocks of various forms have been invented, 
with the view of increasing the motion of the drill, 
of augmenting its power, or, especially, of bringing it 
to bear upon points inaccessible to the straight in- 
strument. Some of these stocks are very compli- 
cated ; as, for example, that denominated Chevaliers 



Ficr. 14. 




drill-stock, than which there are none better adapted 
for bringing the drill to bear in various directions. 



DRILLS. 101 

(Fig. 14.) An other, more simple in construction, 
called Merry s drill-stock, has recently been intro- 
duced to the notice of the profession. With this, 
the drill can be applied at any desired angle, the 
operator having as complete control of the instru- 
ment as of the common straight drill. (Fig. 15.) 

Pk. 15. 




Broaches. — The broaches of three or four sides are 
made of the best steel, and are of various sizes. 
They are constructed both of a straight and of a ta- 
pered form. They should in no case have more than 
a spring temper, in which the color, when drawing, 
is a deep blue. These instruments are used for en- 
larging the canals of fangs for the purpose of filling. 
Six or eight sizes will probably meet all ordinary 
cases. When the course into the canal is tortuous, 
the temper of the instrument should be so low as to 



EXCAVATORS. 



Of the small cutting-instruments for opening and 
forming cavities and removing decay from them, 
there is a great variety, though a few general forms 



102 



INSTRUMENTS FOR FILLING. 



comprise the whole. Hitherto there has been no 
very systematic arrangement of these instruments, 
such as the convenience both of the profession and of 
the manufacturers of dental apparatus would seem to 
dictate. In a classification that we have adopted 
and found very convenient, the classes are arranged 
by numbers, the most simple being placed under the 
first, and under each successive number a more com- 
plicated form. All the varieties are embraced in ten 
numbers, which are represented in Fig. 16. These 



Fig. 16 




varieties are discriminated by the forms of the points 
and their position on the shaft to which they are at- 
tached, and not by any curve which the shaft may 
have at any distance from the point. 



EXCAVATORS. 103 

No. 1 has simply a flat point slightly curved, with 
a round edge transverse to the shaft. Four sizes will 
be sufficient for ordinary purposes. 

No. 2 has a flat point with a short curve, bringing 
the point to a right angle with the shaft ; the edge is 
transverse. This differs from No. 1 in having the 
curve more short and abrupt, and the edge more 
nearly square. Four sizes. 

No. 3 has a flat point with a square, transverse 
edge, which rises at a right angle from the shaft; the 
blade being from one to two lines in length. Four sizes. 

No. 4 has a flat point, curved so as to be at a right 
angle with the shaft ; the blade, from the center of 
the curve to the edge, being from one and a half to 
three lines, and the edge straight. Four sizes. 

In each of the foregoing the edges should expand 
slightly in width. 

No. 5 has a flat point with a square edge, which is 
parallel with the shaft, and rises at a right angle 
from it. The blade is from one half to two and a 
half lines in length, and from one half to one line in 
width, with no expansion at the edge. Six sizes. 

Nos. 6 and 7 are right and left excavators, with 
flat points and double curves; the first curve being 
at an angle of about twenty degrees, and the other 
lateral, right and left, reaching from the beginning of 
the first curve to the point. The length of blade is 
from two to five lines. Four sizes. 



104 INSTRUMENTS FOR FILLING. 

No. 8 has a crescent-shaped point, the blade rising 
by a small attachment from the shaft, and making a 
right angle with it. The edge is a regular curve, 
describing about two fifths of a circle, and is parallel 
with the handle. The point should be perfectly 
formed. Six sizes. 

No. 9. The form of the point is the same as in No. 
8, the difference being in the position of the blade, 
the edge of which is transverse to the shaft, and rises 
from it at an angle of one hundred and thirty degrees. 
Six sizes. 

In No. 10 the point has the same shape as in Nos. 
8 and 9. The cutting edge is transverse to the shaft, 
and rises by a small neck at a right angle from it. 
Six sizes. 

Such are the most important forms of excavators ; 
though modifications will be required for particular 
cases. While Nos. 8, 9, and 10 are not in extensive 
use, a few operators have used them for some years, 
and prize them very highly. In many difficult cases 
they are far more applicable than any other instru- 
ment we have. For instance, in the formation of 
the cervical wall of a proximal cavity in any of the 
teeth, but particularly in the superior bicuspids and 
molars, there is no other instrument so applicable 
and efficient as No. 9 : with it, that part of the cavity, 
so frequently neglected, is just as easily formed as 
any other. 



EXCAVATORS. 105 

Cases will occasionally be presented, in which some 
curvature of the shaft of the instrument will be 
requisite. But no more curve should be given than 
may be absolutely necessary, since it is impossible to 
manipulate with the same precision and delicacy with 
curved as with straight instruments. The degree of 
curve necessary in any given case will be determined 
by the position of the decay on the tooth, and the 
location of the latter in the mouth. 

Of the Manufacture of Excavators. — For making 
these instruments, there should be selected the best 
cast-steel wire, No. 8. This should be forged down 
so as to leave the end large enough to form the 
intended point. Nos. 1 to 6 inclusive, may be 
formed by forging, and afterward dressing up with 
the file. Nos. 7 to 10 must be formed by the files 
out of a bulb left from the forge ; for which purpose 
different forms and sizes of files will be required, in 
order definitely to shape all the angles and points. 
In heating steel, either for forging or tempering, a 
full red heat should in no case be passed, since a 
higher degree than this spoils it. After the points 
are formed, and made smooth with an emery stick 
or wheel, they are to be tempered; which is a delicate 
process, requiring much experience and care. The 
point should be warmed in a spirit-lamp, and then 
covered with soap, to prevent oxydation and scaling. 
The instrument is then brought up to a full red heat 



106 INSTRUMENTS FOR FILLING. 

with, a spirit-lamp, blowpipe, and charcoal, and sud- 
denly plunged into a cake of soap or into cold water ; 
when it will present a silvery whiteness : the steel in 
this condition is extremely hard and as friable as 
glass. It then should be polished off with an emery- 
stick or an oilstone, and drawn down to the proper 
temper. This tempering is accomplished by placing 
the edge of the instrument on a piece of cold polished 
steel or iron, and its shaft near or in the flame of a 
small spirit-lamp, and retaining it there till it changes 
to a deep blue color, graduated down to the point in 
a deep straw or copper hue. The purpose in holding 
the point of the instrument on a piece of cold 
polished iron or steel, is, that the heat there may be 
subject to complete control. The instrument is then 
to be polished with the emery-wheel and dressed up 
with the oilstone. Of the various methods of tem- 
pering, the foregoing is equal, and in convenience 
superior, to any other. 

PLUGGING INSTRUMENTS. 

For introducing and consolidating fillings, a great 
variety of instruments is in use. In filling with gold 
in some of the forms in which it is employed, the 
plugging-pliers are required, for picking up the pieces 
of gold and placing them in the proper positions in 
the cavity; in block-filling they are indispensable. 



PLUGGING INSTRUMENTS. 



107 



These instruments are made of different forms and 
sizes — of different forms, to facilitate access to cavi- 
ties inconveniently located ; of different sizes, to ac- 
commodate cavities of various capacities. For a large 
majority of cases, they require a slight curve, about 
half an inch from the point; for some cases, however, 
the curve will have to be right-angled. (Fig. 17.) 



Fig. 17. 




The points of the pliers, when shut together, should 
form the point of a plugging instrument, so that it 
may be used to some extent for consolidating the 
gold. This instrument should be about five inches 
long, and should have no guidepin. 

The forms of condensing instruments may be mul- 
tiplied to an almost indefinite extent. They are all, 
hxrwever, but modifications of two or three general 
principles. The particular form of the plugging point 
will be determined by the form in which the gold is 
used. With nonadhesive gold, small square, round, 
sharp points, of various curves, will all be required. 
(Fig. 18.) These points are easily kept in proper 
condition, and, in some instances, are used for years 
without any change or repair. But, with adhesive 



108 



INSTRUMENTS FOR FILLING. 



gold.in any of its forms, the points all require to be 
serrated. There are three or four varieties of these, 



Fkr..l8. 




which it will be proper to describe. The first is 
square, and slightly bent about half an inch from the 
end, which is formed into four or six definite sharp 
points with the edge of a thin file. Of this variety 
there should be about three sizes, the largest entering 
No. 18 of Stub's gauge, and the smallest No. 2-3. 
The former should have six points, and the other 
two sizes four. (Fig. 19.) The cuts upon these are 



Fiz. 19. 




made directly across the end. In another variety. 
the end is rounded, and the file placed upon it at an 
acute angle with the side of the instrument, and the 



PLUGGING INSTRUMENTS. 



109 



cuts, three in number, are made to the center of the 
point, which thus becomes triangular, or three- 
pronged, from a common center. (Fig. 20.) Four or 



Fisr. 20. 




s* 



five sizes of these may be employed, ranging from 18 
to 26, Stub's gauge. A thin double point, from 26 to 
28, is in many cases very valuable. Instruments with 
a condensing surface on the side, in stead of the end, 
will frequently be required for filling lateral cavities ; 
these may be denominated lateral pluggers. (Fig. 21.) 



Fijr. 21. 




This condensing surface should also be serrated, as 
already described. An instrument square at the 
point, ranging from 18 to 22, and cut upon the end 
by passing it along the cuts of a file both ways, thus 
making a large number of small serrations at right 
angles across the point, is valuable for consolidating 
the surface of a plug. (Fig. 22.) Operating super- 



110 



INSTRUMENTS FOR FILLING. 



ficially, on the principle of the more deeply serrated 
instruments, it yet leaves the surface free from deep 



Fig. 22. 




pits or indentations, and still so impressed that it will 
receive and retain more gold, if necessary, as it would 
not do, if the end of the instrument were perfectly 
smooth. A smooth-pointed instrument ma}- be ap- 
plied after all the gold has been added. 




Fig. 23 is an instrument with file-cut sides. It is 
valuable for dressing down approximate fillings to a 
uniform surface. There may be two, one with the 
sides parallel with the shaft, and one with its sides 
transverse to the shaft; it terminates in a sharp 
edge. 

In many cases a valuable instrument for consoli- 
dating is the plugging forceps, the general form of 



PLUGGING INSTRUMENTS. Ill 

which, except the beaks, is that of the ordinary 
straight extracting forceps. The beaks are formed 
into sockets for the reception of the plugging points, 
one of which is of the common construction, but the 
other has a broad flat surface, to rest against the 
tooth. (Fig. 24.) This instrument is applicable only 

Fur. 24. 




in certain cases, principally in filling proximal cavi- 
ties. Its main advantage consists in its capability of 
applying a strong pressure upon the filling, without 
affecting the socket. Manipulation with it is less 
rapid and definite than with the ordinary condensing 
instruments ; and with it, too, there is much danger 
of fracturing friable teeth. 

THE FILE. 

Of this valuable and indispensable instrument 
there is a variety of forms used by the dentist. The 
thin files (Fig. 25) are chiefly applicable to the ante- 
rior; the thick, heavy, knife-shaped (Fig. 26), to the 
posterior teeth. The latter, to facilitate their ap- 
proach to the points operated upon, have various 



112 



INSTRUMENTS FOR FILLING. 



curv.es, some single, others double ; the double being 
preferable, since they bring the handle of the instru- 



Fior. 25. 




ment on a line with its cutting edge. The cuts upon 
this instrument, too, are quite various ; in size ran- 



Fi<r. 2G. 




ging from very coarse to very fine, and in obliquity 
from a line almost at right angles across it, to one at 
an angle of fortyfive degrees. These cuts, too. are 
either single or double, the double being those made 
cacross one an other. The single, however, are pref- 
erable for all operations on the teeth; and the more 



THE FILE. 



113 



oblique are to be recommended, since they cause less 
of that jarring, unpleasant sensation to the patient. 

There are in use various forms of file-carriers, one 
of which is represented in Fig. 27, the chief advantage 



Fisr. 27. 




of which is, that they retain the file much more firmly 
than it can be held in the fingers. These carriers are 
made with a variety of curves, to accommodate differ- 
ent positions. There is also a great variety of small 
file-point instruments for dressing down fillings, the 
more important of which are represented in Fig. 28. 

Fi<r. 28. 




The Use of the File. — When a separation of the 
teeth is requisite, preparatory to filling, it is accom- 
plished, either in whole or in part, with the file. 
Principally, in such a case, its use is restricted to 
finishing and smoothing, after the greater portion of 
the work has been done with the heavy cutting in- 



114 INSTRUMENTS FOR FILLING. 

strument, The file is valuable for removing super- 
ficial decay, being called into frequent requisition in 
caries of this kind. It is employed to dress off fangs 
preparatory to the insertion of pivot teeth ; for which 
purpose it is required to be of a round or half-round 
form. It is used for dressing off sharp portions or 
edges of the teeth, that may be injurious to the soft 
parts, and in some cases for dressing down a tooth 
that is elongated. In finishing fillings it is indispens- 
able. It was formerly used to some extent in the 
treatment of irregularity; but for this purpose it is 
now, or should be, abandoned. 

Mode of Using the File. — The patient should be 
conveniently seated, with the head on a firm support, 
and under the control of the operator, who should 
occupy a position at the right of the patient in most 
cases, so disposing the head of the latter as to give 
the freest access to that point which is to be operated 
upon. In manipulating with the file, considerable 
skill and delicacy are requisite. It should not be 
held with a stiff, unyielding grasp, so as to catch and 
jar, but should be applied with a gentle pressure, and 
drawn across the tooth with a free and flexible 
motion. It should be frequently moistened, and not 
allowed to clog with the filings, being kept free of 
these by constant applications of the brush. A 
sharp, new file, with a quick, light movement, will 
cut far more rapidly, and less unpleasantly to the 



THE FILE. 115 

patient, than one that is dull or clogged, applied 
with a heavy pressure. If the tooth bone is sensi- 
tive, the file should be moistened in warm water. 
When a file has become clogged with the dentine, it 
may be perfectly cleaned by immersing it a few 
hours in dilute hydrochloric acid, and then washing, 
boiling, and finishing with oil. The form of a file 
may be changed by drawing the temper, bending it 
as desired, and then retempering. 

The teeth, while being filed, should be supported 
by the fingers, or by an instrument for the purpose ; 
or a cork or a piece of soft wood may be inserted 
between the tooth being filed and the teeth of the 
opposing jaw, and the pressure thus used as a sup- 
port. The tooth being sustained in this manner, 
there is less jarring experienced by the patient, and 
less liability to produce irritation of the periosteum. 
When filing the anterior teeth, it is generally better 
to hold the file in the fingers. For filing the incisors 
and canines, a thin, bevel-edged file is to be pre- 
ferred. In dressing a tooth with a file, the last that 
is used should be a fine one ; after the application of 
which, the surface operated upon should be made as 
smooth as possible with a stone and burnisher, or 
with a buff charged with rotten-stone. 

In separating teeth with the file, where but one is 
decayed, care should be taken not to cut the sound 
one. For this purpose, it will often be necessary to 



116 INSTRUMENTS FOR FILLING. 

have a beveled edge on that side of the file next the 
sound tooth : in no case of this kind should a square- 
edged file be used. In cases in which it is necessary 
to file teeth that are somewhat loose in the sockets, 
and whose periosteum is in a state of irritation, to 
build up a wall of plaster of Paris round them, per- 
mitting it to harden, will very much facilitate the 
operation. This method is especially to be recom- 
mended in cases where it is necessary to dress off a 
considerable portion from the end of one or more 
inferior front teeth. There are some teeth upon 
which the use of the file is hardly admissible; as, for 
instance, those which are highly vascular and predis- 
posed to inflammation of the dentine. Because the 
teeth of young persons are of this character, they 
should be filed but rarely, if at all ; but, in general, 
those of adults may be filed, if properly, with impu- 
nity. The file should not be used upon the teeth, 
when the periosteum, the gums, or the mucous mem- 
brane is in a diseased condition, or strongly predis- 
posed to such a condition. It should never be used 
for the correction of irregularity of the teeth, especi- 
ally when they are sound ; nor should it be employed 
to separate sound teeth to introduce clasps. 

Filing of the teeth is an operation against which 
there has been, and still is, much prejudice, though 
without sufficient cause : whatever injury results 
from this operation, is mostly from the imperfect 



THE FILE. 117 

manner in which it is performed, and from subse- 
quent neglect of the tooth which has been subjected 
to it. A tooth skillfully treated with this instru- 
ment, and properly cared for afterward, will not be 
more liable to decay at the point operated upon, than 
at any other where the dentine may be exposed. 



CHAPTER Y. 

SEPARATION OF THE TEETH. 

In most cases of proximal decay, the teeth, before 
the operation of filling can be performed, must be 
separated; though cases are not unfrequent, where 
the space between them is sufficient to admit of free 
manipulation without this preliminary. An imper- 
fect accomplishment of this first step in the process 
of filling, is a prolific source of the many failures, in 
proximal cavities, to attain to efficient and durable 
results ; for, unless this step be thoroughly performed, 
so as thus to make room for the free introduction and 
use of the various instruments requisite, no part of 
the work can be complete. Though the most com- 
mon object for which teeth are separated, is, to 
obtain space for free manipulation with the instru- 
ments in filling, yet there are various other objects 
for which they have been separated, but many of 
which are now better reached by other means. It 
is sometimes necessary to cut away more than would 
otherwise be requisite, in order to remove thin. 



SEPARATION OF THE TEETH. 119 

friable edges of the cavity, so as to obtain borders 
firm enough to sustain the filling. Teeth are in 
some instances separated for the introduction of 
clasps; a practice always to be deprecated, since it 
usually proves highly injurious. Though the prac- 
tice was once very jcommon, yet many of our best 
operators have now, with good reason, abandoned it 
altogether. At one time, too, it was a general prac- 
tice to separate the teeth to relieve a crowded condi- 
tion ; but this, also, has been abandoned. 

There are two methods of separating the teeth : 
the one, to cut away a portion ; the other, to force 
apart by pressure, acting upon one or more teeth, as 
the circumstances admit. Formerly, all separations 
were effected with the file, and this of very crude 
form and cut; by which instrument, especially in 
unfavorable cases, much injury has been done. 
Though the file is a valuable instrument, one that 
no other could supply, yet, for removal of any con- 
siderable portion of dentine, it is not to be recom- 
mended. Its action upon inflamed dentine is exceed- 
ingly painful, besides being tedious and wearisome to 
patient and operator ; and it is liable to irritate the 
external periosteum, and to increase inflammation. 
When a separation is to be made that requires the 
removal of a considerable portion of the tooth, the 
chisels, or heavy cutting instruments, are to be pre- 
ferred. These, if of the proper form and temper, and 



120 SEPARATION OF THE TEETH. 

in good condition, are very efficient for the purpose, 
performing the work far more rapidly than the file, 
and far less unpleasantly to the patient. They effect 
the removal of sensitive dentine with but little or no 
pain, and without liability to increase the inflamma- 
tion, or to produce irritation or disease of the ex- 
ternal periosteum. The force of these instruments 
is sustained by the entire attachment of the tooth, 
their pressure being applied almost in a line with its 
axis. Besides, by their use, the contiguous teeth are 
not liable to injury, as by the use of the file they 
often are. 

The manipulation with these instruments is very 
simple. For separating front teeth, the instrument 
is firmly grasped in the hand, the thumb placed on 
the points of the teeth, and the edge applied at the 
point from which the portion is to be removed, and 
pressed gradually toward the gums, not thrust into 
the interval as a wedge before it has freely cut its 
way. In this manner, as much of the dentine as it 
is desirable to remove, is cut off in a few moments. 
This class of instruments is invaluable for forming 
the Y-shaped spaces between the bicuspids and the 
molars. It requires a prolonged use of the file to 
make these separations properly; and hence the 
practice of attempting to fill proximal cavities with- 
out any separation at all, by operating through a 
small opening at the crown angle of the tooth, or a 



SEPARATION OF THE TEETH. 121 

small hole drilled through its outer or inner portion. 
With the heavy cutting instruments, points upon the 
teeth, that the file cannot touch, are approached and 
operated upon with facility. 

But the method of separation by pressure is, in 
many cases, to be preferred, especially in the case of 
anterior teeth, whose natural form it is important to 
preserve. In order to a successful separation in this 
manner, there must exist certain conditions. In the 
first place, there is to be sufficient space between the 
contiguous teeth to allow the desired separation ; for, 
if all the teeth are remaining and stand close togeth- 
er, it will be impossible to effect much separation 
by pressure ; but if there is a slight space between 
some of the adjacent teeth, or if a neighboring tooth 
has been removed, the object may be readily at- 
tained. The gums, periosteum, etc., should be in a 
healthy condition; for much injury may be done by 
attempting to separate teeth by pressure, when the 
contiguous parts are in an irritable state. In persons 
of a neuralgic diathesis, in those whose vital energy is 
weak, and particularly in those whose constitutional 
tendency is inflammatory, this operation is scarcely 
admissible. If, in such cases, it is attempted at all, 
it should be proceeded with very carefully and grad- 
ually, and would better be preceded by constitu- 
tional treatment. There are some cases in which it 
is best to make the separation partly by pressure, and 



122 SEPARATION OF THE TEETH. 

then to complete it by dressing off the thin, friable 
edges of the cavity with the cutting instrument or 
the file. Whether the process is to be wholly or 
only partly accomplished by pressure, should be de- 
termined beforehand. 

Various materials have been employed for sepa- 
rating the teeth by pressure, the chief of which are 
cotton, wood, India rubber, and ligatures. The con- 
dition and character of the parts to be operated upon 
will indicate the material best adapted in' any given 
instance. In a good constitution, with the teeth 
firmly set, and the contiguous parts healthy, wood or 
India rubber may be applied ; but in cases of an op- 
posite character, a more }delding and tractable mate- 
rial is indicated. The degree of pressure to be ap- 
plied and continued, will be determined by the 
susceptibility of the parts to irritation. Soreness 
usually occurs in a few hours after the introduction 
of the material. The pressure should be gradual and 
constant, slight at first, and increased in force as the 
patient will bear; the increase being made every day. 
and continued till ample space is obtained. The 
time necessary for the completion of this process is 
from ten to twelve days ; only one separation should 
be made at a time. The teeth should be retained 
apart till the soreness has abated, before the opera- 
tion. If not thus retained too long, they will return 
to their former position. It is by some supposed that 



SEPAKATION OF THE TEETH. 123 

separation by pressure is admissible only in the case 
of the young, or those under thirty years of age. It 
is true that they are the most susceptible; but the 
operation is, under favorable circumstances, proper at 
any age. 



CHAPTER VI. 

FILLING OF TEETH. 

The operation of filling teeth is an interesting and 
important one, requiring for its successful accomplish- 
ment peculiar talent and large experience. It is the 
only means as yet ascertained of completely effecting 
the object for which it is employed, namely, arrest of 
decay and preservation of the organs. Therapeutic 
agents avail but little here, so low is the organization, 
and so feeble the vital power. Nature, so efficient in 
more highly organized structures, does but little, in 
disease of the teeth, toward arrest or restoration. 
Yet, on the other hand, these organs are less liable 
to decomposition by the action of foreign substances ; 
indeed, the enamel is almost invulnerable to any 
agents to which it is ordinarily exposed. The den- 
tine, however, is more easily acted upon, and. when 
there is defect in the enamel, is very liable to injury. 

Scarcely an individual in our country arrives at 
mature age with a perfect set of teeth ; indeed, nine 
tenths of our people have decayed teeth at an early 
period of life. Hence, for beautifying, preserving. 



EXAMINATION. 125 

supplying these organs, art is in constant requisition ; 
and, in these respects, art has made great achieve- 
ments. In the operation of filling the teeth, espe- 
cially, its achievements are conspicuous ; and here is 
scope for the highest skill. Every successive step in 
the process of filling a tooth demands a complete and 
conscientious application of the most efficient and 
best adapted formulas of the art. In the following 
remarks, it is proposed to analyze this whole process, 
examining, in their order, the various steps necessary 
to be taken, and endeavoring to inculcate the true 
methods of accomplishing them. 

EXAMINATION. 

When a case is presented, there should first be a 
thorough examination, since by this all the subse- 
quent work will be modified. The points to be noted 
in the examination are as follows : 

The temperament ; the present health ; the consti- 
tutional tendencies; the secretions, the saliva and 
the mucus; the mucous membrane and the gums; 
the constitution and condition of the teeth ; the num- 
ber of them remaining in the mouth ; the num- 
ber affected ; and the extent and nature of the decay, 
and the character of the agents producing it. By 
the examination we ascertain how to proceed in the 
operation; if much or but little labor is required; 



12(3 FILLING OF TEETH. 

whether the operation will be a simple or a difficult 
one;' and if difficult, what circumstances render it so : 
and, besides, some conclusion is arrived at in regard 
to the permanency of the operation. 

OPENING. 

The next step is to open the cavity of decay, so 
that it may be approached and operated upon at all 
points. The particular manner of performing this is 
determined by the extent of the decay, and its posi- 
tion upon the tooth. In all cases the opening should 
be such as to give free access to all parts of the 
cavity, for removing effectually the decayed portion, 
for perfectly forming the cavity, and for introducing 
and thoroughly consolidating the filling. In central 
crown cavities of the molars and bicuspids, the pro- 
jecting or pendent portions of enamel should be cut 
away. There are cases, however, where such por- 
tions are firm and not liable to be broken, and where 
they can be well sustained by filling under, in which 
it is admissible to leave some projection. This is 
true of only those teeth which are of good, firm 
texture. There are these two objections which may 
exist to these abrupt projections of enamel : it is very 
difficult, and in many cases impossible, to fill perfectly 
beneath such portions ; and again, they are very 
liable to be broken down during mastication. 



OPENING. 



127 



For opening up these cavities, in many cases the 
bur drill alone will be quite sufficient; those of dif- 
ferent sizes being employed, to open up the orifice 
gradually, so that too much violence may not be done 
to the teeth. In all very small cavities, the bur is 
all that is required. 

In cases where the decay is more extensive, and 
the cavity larger, the chisel or heavy cutting instru- 
ment, in connection with the drill, will be found very 
useful. An instrument first brought to the notice of 
the profession by Dr. Forbes, is very valuable for 
opening and enlarging crown cavities of the molars. 
It consists of a socket-handle, which receives a screw- 
clamp, and this receives the bits; which are of 
various forms, such as the gouge-, chisel-, and Y-shape : 
these fit into the clamp, and are grasped by it, as it 

Fi£. 29. 




is screwed into the handle. (Fig. 29.) By its use 
the operation will be very much facilitated, and less 
jarring will be communicated to the tooth ; but after 



128 FILLING OF TEETH. 

it is used, the bur will be required to give a smooth, 
uniform border to the cavity. In these cases, the 
orifice should be almost or quite as large as the 
cavity within. In proximal decay, the cavity must 
be sufficiently exposed to enable the operator to see 
distinctly into it, and to manipulate freely, in all 
parts of the operation. These cavities may be 
exposed by the use of the chisel or the file, or by 
pressure. 

REMOVAL OF DECAY. 

After the cavity is opened, the next step in order 
is the removal of the decayed dentine. As a general 
rule, this should be entirely removed. There is, 
however, some variety of opinion upon this subject. 
This difference of opinion is in regard to cases where 
an entire or a partial decomposition of the dentine 
has taken place quite to the pulp, and where, by its 
removal, the pulp would be exposed. It is main- 
tained by some that decayed dentine affords a better 
protection to the nerve than any artificial covering ; 
and hence it is better to let it remain, since its 
adaptation to the pulp is more complete ; and it is 
not in every sense a foreign substance. 

On the other hand, it is contended that the de- 
cayed dentine, being in an abnormal condition, will 
irritate, and in many cases ultimately destroy the 
pulp. And again, that there is danger of making 



REMOVAL OF DECAY. 129 

undue pressure upon the pulp, in filling on such soft- 
ened portion. 

In many cases, it is maintained that partially de- 
composed dentine will become dense again, if pro- 
tected from the influence of foreign agents that de- 
compose it. This sometimes would seem to be true. 
For in some cases where fillings have been introduced 
into cavities, at the bottom of which a softened por- 
tion of dentine covered the nerve pulp, on removing 
them in from one to five years afterward, the whole 
walls of the cavity were found to be equally and 
normally dense. This, perhaps, would occur only in 
good constitutions, and under favorable circum- 
stances; but with such constitutions and circum- 
stances, where the softening is not too extensive, and 
the decomposition but partial, it may be permitted to 
remain, with a strong probability of a favorable 
result. This would certainly be better than to cut 
it all away and expose the nerve, and perhaps wound 
it, and then endeavor to cover it with some wholly 
foreign material that would not be perfectly adapted 
to it, that would press a little too hard at one point, 
and not touch at an other, and that would be quite as 
liable to be pressed down on the pulp as the softened 
dentine. 

In this discussion, much depends upon the point 
whether partially decomposed dentine can retain its 
vitality. This it is not now proposed to consider. 



130 



FILLING OF TEETH. 



There are some particulars in regard to the removal 
of decay, however, about which there is no diversity 
of opinion : first, that all decomposed dentine should 
be removed from all parts of the cavity, where the 
pulp would not be exposed or injured thereby; and 
that in all cases it should be entirely removed from 
the lateral walls of the cavity, and especially from the 
vicinity of the orifice. Even discolored dentine should 
be removed from this point. 

Dentine often becomes changed in color when 
there is no apparent decomposition ; such portion is 
usually, though not always, without vitality. It is 
not important to remove such changed portion, ex- 
cept for the appearance of the tooth ; it will produce 
no change upon the living or normal part beyond it ; 
and it is better material to be in contact with the 
living part than the metal of which the filling is 
made. 

Decayed dentine is readily removed with the ex- 
cavators. In any given case, such instrument should 
be selected as would be best adapted for the purpose, 
as well in regard to size and the form of its edge, as 
to the curvature, or inclination,, of its shaft. The 
edge of the instrument should come upon the walls 
of the cavity at such an angle as to accomplish the 
work most efficiently. It should be very sharp, and 
pressed firmly to the bottom of the decay at one side, 
so as to remove the principal part at one cut, With 



FORMING CAVITIES. 131 

the proper instrument, and that in the right con- 
dition, all the decay should be removed from any 
cavity by a very few, firm, steady strokes. By this 
method less pain is caused the patient, and the work 
of the operator is facilitated. It is intolerable to 
think of being subjected to an awkward, clumsy 
hand, with a dull, ill-shaped excavator, scratching 
upon the surface of a decayed tooth, for a length of 
time, apparently to the patient, interminable. 

FORMING CAVITIES. 

The next step in the operation is the formation of 
the cavity. By this the cavity is so formed that it 
will retain the filling when properly introduced. In 
very few cases is the cavity of proper form when the 
decay is removed. Much time, patience, and labor 
are required of the operator, for the proper accom- 
plishment of this part of the work, and much endu- 
rance on the part of the patient. Excavation is often 
necessary to give a regular form to the cavity ; and 
in this process there are several particulars worthy of 
consideration. The great object, however, is to give 
to the cavity such a form as will most certainly re- 
tain the filling in place. The cutting for the forma- 
tion of the cavity should be accomplished with the 
least possible loss of healthy dentine; which is a 
point upon which good judgment should be exercised. 



132 FILLING OF TEETH. 

The strength of the walls of the cavity, and the 
ability of the parts to withstand the pressure, both in 
the introduction and consolidation of the filling and 
in the act of mastication, should be well noted. It 
may be regarded as a rule from which there should 
scarcely ever be a departure, that the enamel should 
never be encroached upon in excavating to give form 
to a cavity. When there is but a lining of dentine 
at any given point on the enamel, after the decay is 
removed, it should remain for the preservation of the 
enamel; it should not be cut through either by pits 
or by grooves, much less should any considerable por- 
tion be removed. 

There are cases occasionally in which the dentine 
is wholly decayed, and its removal lays bare the 
enamel ; when such a case occurs, the enamel should 
be retained as perfect as possible, and no attempt 
made to form pits or grooves in it. The reason for 
this is found in the friability of the enamel. 

It may be regarded as an axiom, that where it is 
necessary to cut the healthy dentine to give proper 
form to a cavity, it should be done at that part of 
the cavity where the tooth will suffer least from the 
loss. The precise point and amount of cutting will 
be determined b}^ the form and size of the cavity, and 
the amount of solid dentine remaining after the decay 
is removed. 

In small cavities, where there is sufficient material 



FORMING CAVITIES. 133 

to work upon, the object is to give the cavity a 
regular form, and make the retaining points where it 
is most convenient. 

In large cavities, where one side of the tooth is 
weak, places must be selected for making the retain- 
ing points, that will not affect the weak point. Fre- 
quently, in proximal decays of the anterior teeth, the 
labial and palatal walls are friable, and would be 
easily broken ; much cutting upon such walls would 
not be admissible. Again, the decay often extends 
toward the point of the tooth, down to the union of 
the labial and palatal plates of the enamel ; in cases 
of this kind, all that can be done at this point is to 
remove the decay; and fracture will sometimes occur, 
even in accomplishing this. 

In some cases, as in the crown cavities of the 
molars, the cavity will be nearly or quite of proper 
form when it is perfectly opened up, and the decay 
all removed. This is the case when the decay is 
confined to a simple perforation of the dentine, with- 
out any lateral extensions. In proximal cavities, 
there is always more or less excavation of the solid 
dentine required, to give the cavity proper form. 

There is no definite rule for the formation of cavi- 
ties, that will be applicable in all cases. The form 
will be modified by the tooth, the position of the 
decay upon it, and the extent and ramifications of 
the decay. It is given, by some, as a rule, that the 



134 FILLING OF TEETH. 

depth of a cavity should be equal to its least diameter. 
This is a direction, however, of no general applica- 
tion, for many cavities will be much deeper than the 
greatest diameter, as in crown cavities of the molars ; 
and the reverse will often occur, as in labial cavities 
of the superior incisors, and in proximal cavities of 
the molars, in which it would be impossible to make 
anything like an approach to this rule, without ex- 
posing the nerve, and even cutting through the nerve- 
chamber. 

A general direction, and one that we think good, 
and applicable in many cases, especially in crown 
cavities of the molars, and in almost any of the deep 
perforations by decay, is, to make the walls of the 
cavity as nearly as possible parallel with one an other. 
This rule is applicable in almost all small cavities. 

In medium or large-sized cavities, it is admissible 
to leave them slightly larger at the bottom than at 
the orifice, if circumstances require ; a large cavity of 
this form can be perfectly filled, when a small one 
could not, from the fact that, in the former, there is 
more room to manipulate with the instrument, in 
introducing and consolidating the filling. 

Cavities that are larger within than at the orifice, 
should have their walls perfectly plain, smooth sur- 
faces, free from transverse grooves or depressions, so 
that the gold may be perfectly adapted to them. 

It is sometimes necessary to leave a cavity slightly 



FORMING CAVITIES. 135 

larger at the orifice than at the bottom. This may 
be done by a converging inclination of the wall of 
one or more sides of the cavity. When there is an 
inward inclination of the wall at one side of the 
cavity, the general form may be such as to retain a 
filling perfectly, for there may be two opposite sides 
parallel, or even divergent ; in that case, the axis of 
the cavity will not be in the direction of the center 
of the crown. 

Two opposite sides may converge and the others 
diverge, and a filling be retained firmly. When two 
contiguous sides have the same converging inclina- 
tion, making the orifice larger than the interior, if 
the walls are smooth, plain surfaces, a filling will not 
be retained ; but retaining points may be made by 
forming transverse grooves, or pits upon them, and 
by this means the filling be firmly retained. As a 
general rule, it will be necessary, when the orifice is 
larger than the cavity within, to make grooves or pits 
on the walls. For these the proper points should be 
selected. 

If the cavity is large, and the walls near the orifice 
thin, and liable to be broken, the situation of the 
grooves or undercutting should be farther within the 
cavity than if the walls are firm out to the edge. 
Sometimes it is best to make little pits at the bottom 
of such cavities for retaining points. In cases where 
it is necessary to make an undercutting, one or two 



136 



FILLING OF TEETH. 



little transverse grooves upon one side will be suffi- 
cient, and in no case on more than two sides, leaving 
the others perfectly plain surfaces. 

In the formation of retaining points in difficult 
cavities, there is considerable diversity of practice — 
undercutting and grooving have been very com- 
monly employed. An other method has been very 
frequently adopted during the last three or four 
years, namely, that of drilling little holes or pits into 
the dentine at the most favorable points, these taking 
different directions. This kind of retaining points is 
much better calculated to answer the purpose, in 
filling with crystal gold, or adhesive foil by Dr. 
Arthur's method, than with the ordinary foil after 
the old methods. When these perforations are made 
at different inclinations, and then perfectly filled with 
adhesive gold of any kind, the filling will certainly 
be retained in place. For making these perforations, 
an English broach and a small square-edged drill are 
quite sufficient. 

Such retaining points are seldom or never required 
in crown cavities of the molars ; but in proximal 
cavities they are frequently employed with great 
advantage. In forming them, great care should be 
exercised, lest the nerve-chamber is approached by 
the instrument. In almost all cases, the proper point 
for forming them is at the bottom of the cervical wall 
of the cavity. 



FORMING CAVITIES. 137 

An other particular to which attention should be 
given is the border of the orifice. It should always 
be an object to secure an even, smooth, and strong 
border to the orifice of the cavity. It is impossible 
to make a good finish with a rough, uneven border; 
the filling is also more exposed to injury by mastica- 
tion. The integrity of a smooth, plain surface is per- 
fectly retained under influences that would break up 
and destroy an uneven one. It is also very desirable 
to have a firm margin ; to obtain this, it is often 
necessary to cut away more than would otherwise be 
desirable. A smooth, firm border should not be sacri- 
ficed for the form, and especially in the posterior 
teeth. It is very objectionable to some persons to 
have the perfect form of the front teeth marred or 
changed ; but it should be remembered that even a % 
front tooth, one third cut away, and so filled as to be 
permanently preserved, is far more valuable than an 
artificial one. 

An other particular that should always be observed, 
is, to obviate all acute angles. These are seldom or 
never found in proximal cavities of the molars and 
bicuspids; occasionally they are found in proximal 
cavities of the cuspids, and frequently in proximal 
cavities of the incisors, particularly at that part of 
the cavity next to the cutting edge of the tooth. 
Such angles are very often found also in crown 
cavities of the molars, where there is an extension 



138 FILLING OF TEETH. 

of the decay along one or more of the fissures of the 
crown. 

It is difficult — almost impossible — to fill perfectly 
a sharp angle, and hence the necessity of obliterating 
such when they occur. This may be done either 
with a small delicate cutting instrument, or with a 
small bur drill. It is an operation requiring great 
care and delicate manipulation, at least so far as the 
anterior teeth are concerned. When a sharp angle 
occurs in the proximal cavities of the front teeth, 
it is usually near the cutting edge of the tooth, 
just at the union of the labial and palatal plates of 
enamel. A small chisel-shaped instrument is very 
good for cutting out such angles : indeed, in fissures 
of crown cavities of molars, where the decay extends 
backwards, the straight, chisel-shaped instrument is 
just adapted to this purpose ; but when there is an 
anterior extension, the instrument should be curved 
to almost a right angle, and forced down by pressure 
of the thumb of the left hand. Some good operators 
recommend a slight reaming at the orifice of all cavi- 
ties, where it can be accomplished. The object of 
this is twofold : to remove the sharp angle at the ori- 
fice of the cavity, as it is liable to be roughened in 
putting in the filling ; and to give a better border to 
the filling. In making this bevel, the bur, if one 
is used, should be but little larger than the orifice of 
the cavity. The cutting should be but slight — just 



DRYING CAVITIES. 139 

sufficient to remove the sharp corners ; much cutting 
here would give too thin and yielding an edge to the 
rilling. 

DRYING CAVITIES. 

After a cavity is properly formed, it should be 
thoroughly cleaned and dried. Every particle of de- 
tached bone or foreign substance should be removed ; 
daring the excavation every thing should be kept 
out, every fragment removed as soon as it is de- 
tached ; but generally there is something of the kind 
to remove after the cavity is formed. This may be 
done probably better with a syringe than by any 
other method ; this, however, used in connection with 
a moist lock of cotton on a probe, will serve to re- 
move every extraneous material that may be in the 
cavity. Any foreign substance remaining in the 
cavity prevents a perfect adaptation of the gold to 
the part, and consequently as perfect an attachment 
as would otherwise be obtained. After washing out 
thoroughly, wipe out with successive locks of dry cot- 
ton, till all the moisture is removed. The ordinary 
cotton will not accomplish this very effectually. By 
washing cotton in sulphuric ether, it is much im- 
proved for this purpose. The ether removes a peculiar 
oily substance from it, and thus increases its capacity 
to absorb moisture. Ether or chloroform will either 
answer the purpose; or a boiling of the cotton in 






140 FILLING OF TEETH. 

water in which there is a small portion of carb. soda, 
or some such alkali, for a short time, will accomplish 
the same thing. Bibulous and blotting paper have 
been employed for this purpose ; and by some they 
are preferred. Prepared flax has likewise been used. 
Either of these is no better than cotton well prepared. 
The respect in which the paper is any better than 
common cotton, is, that it has the same treatment in 
effect as the prepared cotton. 

With none of these things can a cavity be made 
absolutely dry. It is not necessary to have absolute 
dryness to make a good filling, yet a more perfect 
filling can be made where that condition is obtained. 
Gold takes a better hold upon a perfectly dry, than 
upon a moist surface. This is quite apparent in the 
following experiment : Place two or three blocks of 
gold in any ordinary cavity, wiped as dry as possible, 
and press them firmly in place, consolidating them as 
much as would be done in filling, and then test the 
attachment by removal. Afterward reduce the same 
cavity to absolute dryness, take the same amount of 
gold, in the same form, and place it in the cavity, 
and consolidate as before, at the same point in the 
cavity; and then test its attachment in the same 
manner. The latter will be found much more firmly 
attached than the former. 

But it is objected that this is useless, inasmuch as 
the natural moisture of the tooth is removed, by pro- 



DRYING CAVITIES. 141 

ducing absolute dryness, and that this will soon 
return, and then the cavity will be no dryer than it 
could have been made with good cotton or paper. 
Admitting this, perfect dryness will remain long 
enough for the introduction of the filling. And if 
this is facilitated by absolute dryness, and a better 
adaptation and attachment obtained, then it is de- 
sirable to obtain that condition. 

It has already been remarked that perfect dryness 
can not be obtained with cotton or paper. To warm 
these on a hot metallic plate, after being wrapped on 
the instrument, will very much increase their effici- 
ency in removing moisture. Asbestos wrapped on a 
small bulb-pointed instrument, and heated, is very 
good for drying out cavities ; with it, perfect dryness 
can be obtained, as it can be reheated and applied 
as often as necessary. To prepare this, select a 
proper-sized bulb-pointed instrument ; a worn-out bur 
drill answers well ; and fold over it fibers of asbestos, 
passing them a little way beyond the bulb on the 
shaft of the instrument, and there binding them 
firmly on with fine platinum wire ; and the instru- 
ment is ready for use. An other method of obtaining 
perfect dryness — one that is very certain in its 
result — is to throw a jet of warm air into the cavity. 
This is accomplished by a little instrument, simple 
in structure and easily used. (Fig. 30.) It consists 
of a small blowpipe with a cylinder an inch long, 



142 



FILLING OF TEETH. 



and half an inch in diameter; this is placed down 
within two inches of the point of the instrument. 
This cylinder is either made of very heavy metal, or 
rilled with wire or something that will retain heat ; 



Fisr. 30. 




on the other end is attached a stiff India-rubber ball 
with an opening one and a half lines in diameter. 
By placing the thumb upon this opening, and making 
compression, a jet of air is forced through the point 
of the pipe, and the cylinder being previously heated, 
the temperature of the jet will correspond with that 
of the cylinder, and the velocity with which it is 
forced through the instrument. This jet thrown 
into a cavity that has been made as dry as possible 
by wiping, soon makes a very perceptible change, the 
walls of the cavity becoming whiter than before. 
This we consider the most desirable condition in 
respect to dryness, that can be obtained. 



INTRODUCING THE FILLING. 

Having, in all the steps for the preparation of the 



INTRODUCING THE FILLING. 143 

cavity, made thorough work, the next thing to be 
accomplished is the introduction and consolidation of 
the rilling. The manner of performing this part of 
the work will be governed by the kind of material 
employed, and also, somewhat, by the form of the 
particular material. Some materials, as gold, for 
instance, may be used in three or four different 
forms, each involving a principle peculiar to itself; 
and each of these forms is susceptible of being used 
in different ways. It is proposed, in the first place, 
to describe the best methods of introducing gold, in 
the various forms in which it is or has been em- 
ployed, considering also the merits of each. 

The first method for consideration is that of filling 
with ordinary gold foil. The principles applicable to 
the use of this kind of foil also obtain in the use 
of foils of other metals. Gold is used far more than 
*any thing else. The common, and, indeed, the 
almost universal method of using foil, at one period, 
was in the form of a roll, or rope, as it was sometimes 
called. By this method, the foil is cut into strips 
from one third of an inch to two inches wide, the 
width being governed somewhat by the size of the 
cavity to be filled. This strip is then rolled length- 
wise, forming a loose roll. The compactness of the 
roll should depend upon the size of the points with 
which it is to be condensed ; the smaller the points, 
the more compact the roll may be. 



144 FILLING OF TEETH. 

It may be introduced either with the condensing 
instrument or with the plugging pliers (improperly 
sometimes called plugging forceps.) 

I^pJth the former, it is taken up at one end on 
the point of the i n str n m PTii . v. r.fofmmmd-fjj^he bottom 
of the cavity ; and that portion within the cavity n 
pressed firmly against the wall where it is desirable 
to begin the filling. There is no definite uniform 
point in cavities, at which to begin the introduction 
of the gold; usually, however, in crown cavities of 
the molars, at the posterior wall. At whatever point 
the filling is commenced, the cavity should be so 
formed that it will retain the first portion of gold in- 
troduced ; and this may be done by forming a little 
pit or groove for the reception of the portion first in- 
troduced. This is a particular that can not with im- 
punity be neglected. The gold should never change 
its position after it is pressed to the wall of the 
cavity ; for it can not be adapted to any other point 
after it is condensed. The end of the roll being 
placed in the cavity, it is seized far enough without 
the cavity to form a fold that will extend to the bot- 
tom, and protrude from one to two lines beyond the 
border of the orifice. This fold is pressed firmly upon 
the preceding portion of gold and adjacent walls. 
Thus fold after fold is introduced, passed to the bot- 
tom of the cavity, and, protruding from the orifice, 
consolidated firmly, each portion as it is introduced, 



INTRODUCING THE FILLING. 145 

being perfectly adapted to the walls of the cavity and 
the preceding portion of the filling. 

It is important to obtain as complete an adaptation 
of the filling to the walls of the cavity as feasible; 
and in orde^ + ~ ~c r . ,# •'■ til*. center should not 

,j imea too rap aly. The gold is thus introduced 
fold after fold till the cavity is full. When it is filled 
to two thirds of its diameter, the gold should then be 
adjusted to all the remaining walls of the cavity, and 
the last portions of gold introduced somewhere in 
the body of the filling, certainly not next to any wall 
of the cavity. A more thorough adaptation of the 
gold can be made to the walls of the cavity, by this 
manner of arranging it, than by introducing the last 
portion at one side of the cavity. There is less lia- 
bility of fracturing a frail tooth by placing the gold 
on the walls first, and terminating the introduction 
of it at or near the center of the filling. It is a very 
common practice to introduce the gold rather loosely, 
or without much condensing, and after being intro- 
duced in this manner, to condense by forcing into it 
a wedge-shaped instrument at various points, and 
filling these perforations with small rolls of gold; 
continuing to use the wedge-shaped instrument as 
long as it can be forced into the filling. This method 
is by no means as efficient as that of condensing each 
portion as it is introduced. By the latter plan the 
filling can be made uniformly dense from the surface 






146 FILLING OF TEETH. 

to the bottom of the filling. This can not be done 
by the use of the wedge-shaped instrument ; it will 
compress most at its largest diameter, that is, at the 
surface of the plug. 

In no filling, even when the walls of the cavity are 
parallel, will a uniform density throughout be ob- 
tained by perforating with the wedge. The filling 
would be most dense at the surface, and less so the 
farther into the filling we go. This method is objec- 
tionable for condensing the fillings on the masticating 
surfaces of the molars; for in the act of mastication 
the inner portion would yield, and the surface of the 
filling would be crowded down into the cavity, and 
the dentine within the orifice become exposed and 
decay. In proximal fillings this objection would not 
have the same force. In forcing an instrument of a 
wedge form into a filling with sufficient force to con- 
dense the mass, there would be great danger of break- 
ing a weak wall of the cavity. The principal pressure 
is lateral, and would consequently come upon the 
side of the tooth. 

In crown cavities of the molars where there is any 
considerable inward expansion of the cavity, that 
method of condensing would be wholly inefficient ; it 
would not render the inner portion dense enough to 
support the surface of the plug, and it would be 
forced down, and necessarily be loose. In filling the 
proximal cavities of the incisors, it is very objection- 



INTRODUCING THE FILLING. 147 

able on account of the great liability of breaking the 
inner and outer walls, which are usually quite thin. 

In preparing the foil for filling, some operators tear 
off the foil in irregular pieces, and make into little 
balls or pellets, round and loosely rolled, correspond- 
ing in size with the cavity to be filled. These pellets 
are placed in the bottom, if a crown cavity, and at 
one side, if a proximal cavity, and condensed with a 
sharp-pointed instrument, attaching one pellet to an 
other till the cavity is full. This mode is not so 
good as that previously referred to, unless the gold is 
in a condition to weld perfectly ; there is no con- 
tinuous portion from the bottom to the orifice of the 
cavity ; and the outer portions are liable to become 
detached. Both of these methods of arranging the 
gold are objectionable in one particular, namely, the 
irregularity of the leaves or laminae of the foil ; these 
are placed in the cavity without any regard to regu- 
larity, and the consequence is, that without very 
great care, far less gold will be introduced than by 
some other arrangement. Far more difficulty is ex- 
perienced in obtaining a uniform and equal density 
than when the laminae are placed smoothly together. 

An other method of preparing the foil is to fold it 
into from four to twelve thicknesses, then cut off 
strips in width corresponding to the diameter of the 
cavity. The strip thus prepared is introduced in the 
same manner as the roll, except that as each fold is 



148 



FILLING OF TEETH. 



inserted, it is placed smoothly against the preceding 
portion, and kept smooth and free from wrinkles. 
By this arrangement very little force is required to 
bring the folds in perfect contact. Some care and 
skill will be necessary to bring the instrument to 
bear upon the whole surface of the fold. More "old 
can be put into a cavity in this manner than in rolls 
or pellets, unless these are used in very small por- 
tions, and condensed very perfectly as they are put in. 



BLOCK FILL I 

An other and in some respects far preferable 

method, is filling with blocks. Some of the advant- 
ages of this method over that just described, are the 
following : the filling can be introduced far more 
rapidly; and the laminae, or leaves of foil tak 
more perfect position in the cavity, and consequently 
the structure of the filling is better. The form of 
the cavity should be much the same as that for any 
other method of filling; there should be some retain- 
ing point so situated that the first block, or bio 
can be fixed firmly in place, so that there will be 
no liability of loosening during the subsequent part 
of the process. It is important to have such an ar- 
rangement, as otherwise it would be necessary to 
employ an instrument in the left hand to retain the 
first blocks in situation, till enough were introduced 



BLOCK FILLING. 149 

to bind the whole by pressure upon two opposite 
points in the cavity. 

Forming Blocks. — For forming blocks, use any 
number of foil that may be desired, usually No. 4 or 
6, and either lay four to six sheets together, or fold a 
single sheet into that number of thicknesses; then 
cut off, from the sheets thus prepared, strips about 
one third to one fourth wider than the depth of the 
cavity to be filled ; which are then rolled on a small 
three-sided or four-sided broach — the three-sided is 
better; and this instrument should be very small; no 
larger, indeed, than is indispensable for strength. 
Its sides should be perfectly smooth, and its angles 
sharp ; ordinarily it should not taper, or at least very 
slightly. For forming the conical blocks, some prefer 
the tapered broaches, but they can be as well made 
on the parallel-sided instruments. The strip being 
taken between the thumb and the index linger, is 
rolled on the broach equally, till the block or cylin- 
der is large enough, when the strip is broken off. 
The sizes of the principal part of the blocks should 
correspond with the sizes of the cavities to be filled. 
Different sizes and forms will be required in almost 
all cases. Relatively large cylinders may be em- 
ployed for the principal part of the filling. If the 
walls of the cavity are parallel, almost all the blocks 
may be truly cylindrical; but if there is an under- 
dipping of one or more of the walls, the blocks ad- 



150 FILLING OF TEEin. 

justed to that particular part should be cone-shaped, 
corresponding to that underdipping. A number of 
small graduated cone-shaped blocks, of different de- 
grees of density, will be required for completing each 
filling; as the aperture becomes smaller, smaller 
blocks will be needed. The cone-shaped blocks are 
formed, by gradually running the strip back from the 
point of the instrument as it is wound on ; greater or 
smaller taper can be given to it. as the strip is run 
less or more rapidly back from the point. i 
density of the block can be regulated by the firmi 
with which the strip is held between the thumb and 
finger; upon which it is well to have a fine silk or 
India-rubber covering to protect the gold from the 
perspiration of the hand. There are other met) 
of forming blocks. They may he made square, by 
making a great number of folds— fifteen to thirty — 
and from this, cutting strii lure di and 

then from these heavy strips cutting (.if the blocks 
the desired size, which will then he tlat or nearly 
square. In one respect these blocks are objection- 
able: the edges, when they have been cut off, are 
rendered dense by the action of the shears, bo that 
they do not possess the uniform density or cone 
ence of the rolled blocks, and it is impossible to adapt 
them as perfectly to the walls of the cavity, or to 
an other. This objection, however, may be obviated 
by cutting off the blocks with a verv fine saw. 



BLOCK FILLING. 151 

An other method of forming blocks, first employed 
by Dr. Blakesley, is to roll a sheet of No. 5 foil into a 
rope, and cut off from it blocks corresponding with 
the size of the cavity to be filled. These are liable 
to the same objection as those last mentioned, the 
shears hardening them, when they are cut off. They 
are subject to the additional objection, that the folds 
of foil are not as regular as by either of the other 
methods. But by proper manipulation, with the gold 
prepared in this manner, superior fillings may be 
made. The cavity formed, and the blocks prepared, 
the next step is their introduction. 

Introducing the Blocks. — For placing the gold into 
the cavity the plugging pliers will be required ; the 
points of which should be curved, so as to make the 
most perfect approach to the cavity. The points, 
too, if properly formed, may be used for condensing 
the blocks. All things being ready, with suitable 
napkins and guards for the protection of the cavity 
against the encroachment of moisture from the saliva 
and breath, the fingers of the left hand should press 
upon the napkin, and also hold away the soft parts. 
If there is a very acute angle, a small block should 
be first introduced with the pliers into the proper 
position, one end upon the bottom of the cavity, and 
the other protruding from the orifice, and pressure 
then be made upon it to consolidate it, and force it 
into its position against the wall of the cavity. This 



152 FILLING OF TEETH 

may be done with the pliers, or probably better with 
an instrument formed for the purpose. The part of 
the instrument brought to bear upon the gold should 
be roughened either longitudinally or transversely, so 
that a proper surface may be left for the reception of 
the succeeding portions. The largest blocks are then 
introduced and consolidated successively as described. 
The end of each left protruding till the cavity is 
filled, each portion as it is introduced, should be per- 
fectly condensed. The gold should be filled in fa 
at the sides of the cavity than in the center, thus 
being disposed round the walls till it meets at a point 
opposite the place of beginning: and thus it ii ada] 
to all the walls of the cavity before this is entii 
filled, the last portions being introdl* 
near the center of the filling. As the cavity dimin- 
ishes by the introduction of the gold, the small and 
more dense blocks will be required ; which should be 
forced in and condensed, by crowding an instrument 
down against the side of the cone. Some opera! 
terminate the filling against the wall of the ca\ 
forcing down the blocks and oomprefli >ve, 

till it is full. By this method there is danger o( 
fracturing the tooth, breaking down the wall of the 
cavity, when the filling is terminated. An other 
method is to fill up the cavity principally with 
blocks, and to put in the last part of the filling in 
the strip, fitted in from the bottom to the orifice. 



BLOCK FILLING. 153 

The objection to this method is, that unless adhesive 
foil is employed, the portion inserted in the strip is 
liable to be displaced, and in this way the whole 
filling to become destroyed. 

An other method of arranging this kind of filling, 
particularly when the bottom of the cavity is ir- 
regular, is to make a large, flat pellet, press it firmly 
into the bottom, and set the blocks upon this for a 
foundation. By this method there is a more perfect 
adaptation of the gold to the bottom of the cavity, 
than by placing the ends of the blocks down upon an 
uneven surface. After the gold is all introduced, a 
small-pointed plugger must be passed all over the 
surface, to consolidate the protruding portions and 
form a surface to the filling. These protruding por- 
tions should be sufficient to make the surface per- 
fectly flush with the border of the cavity ; for a de- 
pression here is fatal to a complete finish. After the 
surface is condensed with the fine and large points, 
it may be rubbed down with an instrument serrated 
upon the side, and afterward with the coarse file, and 
then with the fine, etc. 

Dr. Badger describes a method of filling a small 
cavity on the posterior proximal portion of a second 
molar, the third molar gone. The cavity is formed 
with a bur drill. A cylinder is then formed in the 
usual manner, and forced through a series of holes in 
a drawplate, down to the size of the bur with which 



154 



FILLING OF TEETH. 



the cavity is formed. The block is thus rendered 
quite dense. The cavity is then dried, and the block 
forced into it, which it exactly fits, protruding a little 
from the orifice. This block is pierced in the center 
with a sharp instrument, and a small dense roll forced 
into it ; and all is then condensed and finished in the 
usual manner. 

Pellets. — Pellets made by rolling fragments or 
pieces of foil between the thumb and fingers, are used 
by some operators, and with them they' profess to 
make as good filling as by any other method. They 
are made of various sizes, and packed into the cavity 
with sharp-pointed or serrate-pointed instruments. 
The pieces may thus be very solidly worked to- 
gether, and a good filling made, provided the pellets 
are not too large; they should be small enough to 
permit the point or points to work through them into 
the preceding portions. Some operators use pellets 
and crystal gold together. This may do very well, 
if the adhesive property of the gold is employed; but 
in that case, either form of the material would answer 
alone. There can not be as much gold put in bv 
pellets as by blocks well adjusted. 

Adhesive Foil. — By this we understand that condi- 
tion of gold foil in which the leaves unite very readily 
and very firmly togther. This property of cohesion 
is possessed, in the greatest degree, by properly manu- 
factured foil, immediately after annealing. Not that 



BLOCK FILLING. 155 

annealing imparts any new property to the gold, but 
it removes obstacles to the manifestation of a principle 
possessed by all gold under favorable circumstances. 
It is now about four years since this property was 
first employed in gold foil for filling teeth. To Dr. 
E. Arthur is due the credit of first directing the 
attention of the profession to it. He not only did 
this, but he entered most fully into the details of the 
manipulations, instruments, etc., pertaining to this 
mode of operation. Almost all recently prepared 
gold foil possesses this property to a greater or less 
degree ; there are methods of preparing it, however, 
by which it possesses it most fully ; all recently 
annealed foil is adhesive. If the foil is adhesive 
when we wish to use it, nothing further is required 
in the way of preparation. But if it is not adhesive 
— as almost all foil is not, especially if it has been 
exposed to the influence of the atmosphere — it will 
require to be made so by some process : there are 
two, either of whicb will perfectly accomplish the 
object. 

The one most frequently employed, is that of heat- 
ing the gold, either in the sheet, in the roll, or in 
fragments, over the flame of a spirit-lamp, almost or 
quite to a red heat ; if in the sheet, it should be laid 
upon a piece of wire gauze, and passed over the flame 
of the lamp for a moment or two ; if in the roll, it 
may be taken in the center with fine pliers and 



150 



FILLING OF TEETH. 



passed rapidly through the flame ; if in small frag- 
ments or pellets, placed upon a piece of charcoal and 
a light flame thrown upon them with a blowpipe. 
The other method is that adopted by Dr. Coates. 
Into a little platinum pan, large enough to hold an 
unfolded sheet of foil, are put one or two gills of rain 
water, to which are added about forty drops of sul- 
phuric acid; and in this liquid the foil is boiled a 
few moments over the flame of a spirit-lamp. The 
acid removes all foreign substances from the surface 
of the gold. Remove it from the boiling liquid, and 
in a moment it is dry and ready for use, and will be 
most thoroughly adhesive. 

There are different methods of using gold in this 
condition; but in general the cavity should be formed 
about as for the other methods of filling, except that 
to retain the first piece, there should be two or three 
small pits or holes made for retaining points in the 
most available position. The first portion of gold 
should be a little pellet ; this forced into these re- 
taining points, serves as a foundation for the remain- 
ing portion of the filling. Dr. Arthur's method is, 
then, to tear off fragments from the sheet, and pa>.< it 
into the cavity without folding up, and condense it 
with a fine serrate-pointed instrument, so that it not 
only unites by cohesion, but it is worked into the 
surface of the preceding portion of gold; and in this 
manner portion after portion is introduced and con- 



BLOCK FILLING. 157 

densed, until the cavity is full. The filling may be 
commenced in any part of the cavity that is most 
convenient; in many, as in crown cavities of the 
molars, at the bottom, and filled to the orifice. In 
putting in the gold, it should, during its introduction, 
be kept fuller about the walls of the cavity than in 
the center; by this means the adaptation will be 
most perfect to the walls, and there will be no lia- 
bility of clogging up the center. The gold may thus 
be built up to any desired extent if the filling is kept 
dry ; moisture is fatal to its adhesiveness. 

Others use the adhesive gold in a different manner. 
To Dr. Blakesley belongs the honor of first detail- 
ing the following plan : The sheet of gold may be 
folded or not at the pleasure of the operator, and 
then each sheet cut into from two to six strips, and 
these formed into a loose roll between the thumb and 
fingers. It may now be passed rapidly through the 
flame of a spirit-lamp to remove any foreign sub- 
stance that may be upon it; when it is cut into little 
blocks or pellets of various sizes ; these to be regu- 
lated by the size of the roll and the amount cut off. 
For the introduction of the gold thus prepared, about 
three sizes of serrate-pointed instruments are re- 
quired, those having fine points being preferable. As 
to the sizes of these points, Dr. Blakesley remarks, 
"they will just enter, respectively, No. 22, 24, and 
26 of the wiregauge." A larger than either of these, 



158 FILLING OF TEETH. 

however, is desirable for many cases. As before, the 
filling may be commenced at the bottom of the cavity 
or at one side, if desirable, with a pellet sufficiently 
large to be set firmly into the retaining points. Then 
take up the small pellets or blocks upon the point of 
the plugging instrument, and place them exactly in 
the desired position, and consolidate them perfectly, 
building up next to the wall all around higher than 
the center with the smaller pieces, filling up the little 
corners and interstices ; for which manipulation the 
smaller points will be required. The gold is then 
packed in till the cavity is full, when it is finished as 
usual. An other method is to tear off fragments from 
the sheet, and roll these up into round pellets, and 
fill with these, with the same instruments and upon 
the same principle as above described. But by this 
method it is difficult to make a perfect filling ; the 
gold is liable to clog in the cavity, and fail in adapta- 
tion. 

Adhesive gold must be consolidated as it is intro- 
duced; for after a cavitj 7 is full, it is very difficult 
then to condense it any more, even though the con- 
solidation is but partial ; and much more is this true 
of nonadhesive foil. 



CRYSTAL GOLD. 

The form of the cavity for crystal-gold filling, 



CRYSTAL GOLD. 159 

should be much the same as that described for other 
fillings, except that the same care is not necessary for 
special retaining points ; for the first portion of gold 
that is introduced into the cavity, as good crystal 
gold, will attach to the wall of the cavity without 
any such special retaining points : such a form should 
be given as to secure the first piece firmly in place. 
The gold should be cut or broken into pieces cor- 
responding in size to the cavity, so that they will 
enter freely into it. 

The filling may be commenced upon the bottom of 
the cavity, or upon one of its sides ; such a point 
always being selected as will most effectually retain 
the gold in place. The pluggers should be of various 
sizes — the first one as large as can be used in the 
cavity, and smaller ones for condensing more thor- 
oughly 5 and all should be serrated with from two to 
six sharp points, usually four. The blocks may be 
taken up on the points of the plugger, and passed to 
their proper position in the cavity, and there con- 
densed. The sharp, serrated point leaves the surface 
in good condition for the reception of the next piece. 
The gold should be packed to the walls of the cavity 
a little in advance of the center, so that its adapta- 
tion may be more complete. In this manner, the 
filling is built up as much as is desirable, if it is kept 
dry — and unless it is, all cohesion is lost. 

The gold, after it is cut up, is put on a piece of 



1G0 FILLING OF TEETn. 

charcoal, and annealed with a blowpipe, by the flame 
of a spirit-lamp, carefully, so as not to fuse any of the 
particles, as that would impair their facility of cohe- 
sion in this process : very minute portions are often 
required to fill up small interstices, or notches. 

In crown cavities, the filling should begin at the 
bottom ; in proximal cavities, at the cervical wall. 
By introducing the gold in this manner, the pressure 
is made on a line with the axis of the tooth ; which 
is an important consideration. The surface of the 
filling should always be convex, though in some 
cases but slightly, except where the antagonism of 
the teeth prevents, as in the crown fillings of the 
molars — in which case, it should be adapted for the 
reception of the opposing tooth. Proximal fillings 
should usually be a little convex; yet many good 
fillings of this class are effected with a surface per- 
fectly plain with the borders of the cavity. The 
borders of the filling, however, are better protected 
when it is somewhat convex. 

Crystal gold, of perfect character, presents to the 
walls of the cavity a surface better calculated to be 
retained, than foil in any of its forms ; though adhes- 
ive foil possesses this advantage to a greater extent 
than foil in any other condition. The points and 
edges of the crystals are brought in contact with the 
walls, and made to take a firmer hold upon the 
dentine. 



CRYSTAL GOLD. 161 

In forming crystal gold into a solid mass, two prin- 
ciples are operative : cohesion acts upon it as poten- 
tially as upon gold in any other form, and, in addi- 
tion, there is the interlacing, or locking, of the 
crystals with one an other; so that a more perfect 
union of the different portions of which a filling is 
composed, is obtained with crystal gold than with 
foil. Yet good adhesive foil, when thoroughly 
worked in, attains almost the same condition. With 
perfect crystal gold, however, some advantages may 
be secured, that can not be had with foil. The gold 
will be retained in a cavity that will not retain a foil 
filling; it is more easily formed into a coherent mass; 
it can be built out with more ease ; cavities can be 
filled with it that can not be filled with foil at all ; 
and a filling of it is susceptible of a far better finish, 
with the same labor, than a filling of foil. 

It is important to keep the gold perfectly free from 
moisture, while being introduced and consolidated; 
for moisture instantly destroys its cohesive property. 
And the more complete the exclusion of moisture 
from the cavity, during the process, the better for 
the success of the operation. The surface of every 
filling should be consolidated for finishing, before it is 
allowed to become moist; for, whenever it becomes 
saturated with moisture before consolidation, it is 
impossible to make a perfect finish. There should 
always be gold enough superadded to insure this; 



162 FILLING OF TEETH. 

and the consolidation of the last surface should be 
effected with a rough-ended, not serrated, instrument. 

FINISHING FILLINGS. 

The method of finishing a filling, and the manipu- 
lation, will depend somewhat on the locality of the 
cavity. When this has been completely filled, and 
the filling thoroughly consolidated over all the sur- 
face, and especially all round its border, the file 
should be applied to dress off any projecting portion, 
and render the filling smooth. In consolidating the 
surface, an instrument should be used, that would not 
pit it, and the file should remove all indentations. 
The work of the file, however, should be but partially 
peformed at first, and the surface consolidated again, 
with a square-pointed instrument. To obtain the 
most perfect finish, the surface should be brought to 
a uniform consistence ; and this condition can not be 
reached by the use of sharp-pointed instruments, nor 
fully by that of the blunt plugger at the first effort, 
but by the alternate use of the file, the blunt con- 
denser, and the burnisher. A coarse file should be 
employed in this part of the process ; but when the 
filling is dressed sufficiently, and in good condition, 
the fine file should be used, alternately with the 
burnisher, till a perfectly uniform surface is obtained. 
In all cases, after the file has been applied, the plug 



FINISHING FILLINGS.' 163 

should be washed off with a brush, to remove all 
detached pieces of gold, before the burnisher is put 
upon it ; and after the fine file and burnisher, the 
Scotch- or Arkansas-stone or very fine pumice should 
be employed to remove the filemarks. The pumice 
may be applied with water on a strip of chamois skin, 
a piece of linen tape, or a stick of soft wood — the 
latter being the most convenient, as it can be used 
with one hand and shaped to suit any place or 
position. 

After the stone or the pumice has accomplished its 
work, and the filling has been thoroughly washed, a 
fine burnisher, with a solution of castile soap, is em- 
ployed to give the finish. The burnisher should be 
of the best cast steel, and of high temper and fine 
polish. Considerable skill is requisite to give the 
best effect with the burnisher; it should pass 
smoothly and gently over the surface, throughout its 
whole extent, and in parallel lines, with a pressure 
neither too light nor too heavy. It should also be 
applied very thoroughly upon any portion of the 
tooth about the border of the filling, that may have 
been cut by the file or any other instrument. In- 
deed, quite as much, if not more, care should be exer- 
cised upon this as upon the plug itself: it should be 
polished as smooth as the enamel, if possible ; for the 
more nearly perfect it is in this respect, the better 
will it resist the action of deleterious agents. 



164 



FILLING OF TEETH. 



This method of finishing gives to the filling a per- 
fect metallic luster; which, under some circum- 
stances, might be objectionable. Two other methods 
are in use : after the burnisher has been applied, as 
above, the buff or tape, with rouge, may be employed, 
by passing it rapidly over the filling till the metallic 
luster is destroyed, or deadened, so as not to reflect 
the light as before, thus leaving a very desirable 
finish ; and the other method is, to stipple over the 
surface of the burnished filling with the end of a 
piece of hard wood — sandal wood is recommended — 
charged with finely pulverized pumice. This gives a 
beautiful, velvetlike surface, and is fine for fillings in 
the anterior portion of the mouth, where they are 
exposed to view. Eotten-stone, applied either with 
the buff or with hard wood, imparts a finish which, 
though a little different, is finer than any of the 
others. 

For finishing, some operators prefer to cut and 
polish, instead of filing and burnishing. But neither 
so good nor so fine a finish can be effected in this 
way, and it is probable that economy of time and 
labor, especially the latter, suggested the method. 
In all cases, the filling should have a distinct and 
definite margin : the gold should be trimmed off quite 
up to the border of the cavity, by passing round it a 
small, sharp instrument, so as to detect and pare 
down any portion that might overlap the tooth. 



FINISHING FILLINGS. 165 

For, if overlapping portions are permitted to remain, 
foreign substances will lodge beneath, and induce 
decay. Neglect in this particular has occasioned the 
loss of thousands of teeth that otherwise might have 
been saved. 

The subject of finishing is almost entirely over- 
looked by very many operators ; but by the neat and 
skillful it is esteemed of sufficient importance to de- 
mand as great labor and pains as any other part of 
the operation. 



CHAPTER VII. 



CLASSIFICATION OF DECAYED CAVITIES. 



The following classification of decayed cavities in 
the teeth, though from the very nature of the sub- 
ject imperfect, will be found sufficiently accurate for 
the purposes of the dental student and scientifician. 
It is based primarily on the position of the cavities, 
and secondarily on the extent of the decay; the 
classes having reference to the former, and the modi- 
fications to the latter. The classes are numbered ac- 
cording to the accessibility of the cavities, beginning 
with those most easily approached and operated 
upon ; and the modifications according to the extent 
of the decay, beginning with the smallest and sim- 
plest in form. 

First Class. — Central crown cavities in the molars 
and bicuspids. 

1st Mod. — Extension of the decay along one or 
more fissures. 

2d Mod. — Two decays in close proximity on the 
same crown, which may be formed into one cavity 
for filling. 



CLASSIFICATION OF DECAYED CAVITIES. 167 

Second Class. — Cavities in the buccal and palatal 
surfaces of the molars and bicuspids, and in the labial 
and palatal surfaces of the canines and incisors. 

1st Mod. — Extension of the decay beneath the 
margin of the gums. 

2d Mod. — Extension of the decay so as to involve a 
portion of the crown surface. 

Third Class. — Anterior proximal cavities of the 
bicuspids and molars. 

1st Mod. — Extension of the decay toward the neck 
of the tooth, beyond the termination of the enamel. 

2d Mod. — Extension of the decay so as to involve 
a portion of the grinding or crown surface. 

Fourth Class. — Proximal cavities of the incisors 
and canines. 

1st Mod. — Palatal wall of the cavity broken away. 

2d Mod. — Labial wall broken away. 

M Mod. — The cavity at the point of the tooth, ter- 
minating at the surface. 

4t7i Mod. — The borders of the cavity very thin, and 
the lateral walls inclining to the center. 

Fifth Class. — Posterior proximal cavities of the 
molars and bicuspids. 

Modifications same as those of third class. 

Modifications common to all the classes : — 1st. Su- 
perficial cavity and a large orifice. 2d. Deep cavity 
and a small orifice. 

Modification common to classes three, four, and 



168 CLASSIFICATION OF DECAYED CAVITIES. 

five : — Transverse extension of the decay round one 
or more angles of the tooth, under the termination of 
the enamel. 



FILLING BY CLASSES AND MODIFICATIONS. 

First Glass. — Central cavities of the molars and 
bicuspids. These decays always begin in the depres- 
sions on the masticatory surfaces, which are vulner- 
able points, the enamel-membrane folding together 
here, and often being found imperfectly united, so 
that an opening is left into the dentine : besides, these 
indentations afford lodgment for foreign substances, 
which may be forced into them in the process of 
mastication, and there retained, till, becoming 
vitiated, they produce decay. Examine carefully the 
extent and the nature of the decay, and the form of 
the cavity, which, of course, greatly varies. In some 
cases, the cavity is found with a small diameter and 
a comparatively great depth, the diameter at the 
orifice being the same as within ; in others, with a dia- 
meter larger at the orifice — as occurs in cases in which 
a considerable portion of the enamel at the depres- 
sions on the crown is imperfect. In the majority of 
instances, however, the diameter of the cavity is 
much larger within than at the orifice. Sometimes the 
decay is found to burrow directly beneath the enamel 
more rapidly than at any other point; as where there 



FILLING BY CLASSES AND MODIFICATIONS. 16 ( J 

is an imperfect union between the enamel and the 
dentine. In other instances, the cavity seems to 
expand uniformly as it extends into the tooth. 

The manner of opening up and preparing the 
cavity for filling, will depend somewhat on the form 
given to it by the decay. If it is larger at the orifice 
than within, there will be little or no cutting of the 
cavity about the orifice necessary; and its prepara- 
tion Avill consist in an entire removal of the decay, 
and such a shaping of the interior as will insure a 
perfect retention of the filling. This may be effected 
either by enlarging the cavity within, till its walls 
are parallel with each other, or, if these are left con- 
verging, by forming pits or grooves upon them at 
proper points. Converging walls present one or two 
advantages, which will be hereafter considered. 
Usually, where the decay has formed a cavity of 
nearly uniform diameter from the orifice to the bot- 
tom, all the preparation for filling that is requisite, is 
a thorough removal of the decay. In cases in which 
the decay burrows under the enamel, the projecting 
portions are to be cut down, either with a bur drill, 
or, what is generally better, with a heavy cutting 
instrument. In most instances, it is best to cut away 
the enamel as far as the decay has extended beneath 
it, since it is difficult to make a perfect filling under 
a projecting portion. In some cases, however, where 
the enamel is thick and firm, it may be admissible to 



170 CLASSIFICATION OF DECAYED CAVITIES. 

leave a slight projection, so as to form, as it were, a 
shallow groove. 

The walls of these cavities will he of various in- 
clinations. If they converge, pits or grooves may be 
required upon them for retaining points, especially if 
the enamel be cut away at the orifice to the "solid 
dentine. If, however, the walls, or two opposite 
walls, are parallel, or but slightly divergent, these 
special retaining points will not be necessary. Small 
cavities of this class may be opened up and formed 
principally with the bur drill ; but in large cavities, 
this instrument is not available. Thus the orifices of 
the small cavities would be round, while those of the 
large would be of various forms, determined by the 
direction of the decay; as, round, square, triangular, 
elliptical, parallelogramic. Cavities should not be 
formed much larger within than at their orifices, un- 
less the filling can be consolidated so perfectly that it 
will not yield in the least under the greatest pressure 
of mastication ; for, if there is an}' yielding in such 
cases, under direct pressure, the filling being forced 
into a larger part of the cavity, withdraws from the 
walls, leaving an interval coextensive with the de- 
pression it has undergone ; and thus fluids would be 
admitted in between the walls and the filling, and 
the purpose for which this was inserted would be 
entirely defeated. 

Many operators ream the orifices of all the small 



FILLING BY CLASSES AND MODIFICATIONS. 171 

and medium-sized cavities of this class, in order 
thereby to make a better finish to the border of the 
tilling. All acute angles in these cavities, especially 
if they extend to the orifice, should be obliterated, 
since it is impossible to fill them perfectly. This 
obliteration can be effected with a miniature chisel, 
or with the appropriate excavator. 

After the formation of the cavity, the next par- 
ticular is so to arrange as entirely to exclude moist- 
ure, whether from the saliva or from the breath. 
Ordinarily, in operations on the superior teeth, the 
following arrangement will be sufficient for the pur- 
pose : Wipe dry the mucous membrane about the 
mouth of the duct-of- Wharton ; lay directly upon 
this a piece of heavy blotting paper, or a roll of bibu- 
lous paper; then take a napkin folded cornerwise, 
place the end of it upon the paper, between the 
cheek and the gum, passing it back of the tooth to be 
operated upon, along the palatal surfaces of the teeth 
and the gums to the anterior part of the mouth, and 
letting a fold of it extend down from this, so as to 
protect the tooth from the breath, and catch any frag- 
ment of gold that may drop from the instrument. 
The napkin and paper thus arranged, are to be kept 
in their place by the fingers of the left hand of the 
operator; and, if the mouth of the duct is kept closed 
by the paper, a complete exclusion of moisture is se- 
cured. In some cases, pressure of the fingers on the 



172 



CLASSIFICATION OF DECAYED CAVITIES. 



napkin over the duct is necessary; in others, the 
paper adheres to the mucous membrane, and effectu- 
ally prevents the egress of saliva. The cavity should 
now be dried by the method heretofore described, and 
it is ready for the filling. 

In operations on inferior teeth, more care is requisite 
to exempt them from moisture. Bibulous paper 
should be packed in on the mouths of the sublingual 
and submaxillary ducts, and a roll of paper placed 
between the cheeks and the teeth. A larger roll of 
napkin, too, than that used for the upper teeth, 
should be disposed in the same manner as above sug- 



31. 






gested, and held in place by the patient with a 
speculum (Fig. 31), or by the operator and patient 



FILLING BY CLASSES AND MODIFICATIONS. 



173 



with their fingers. Various appliances have been 
used for holding away the cheek, keeping down the 
tongue, and retaining the jaws apart; but the method 
above given, with the addition of a cork to hold apart 
the jaws, will be found efficient in a majority of cases, 
and more convenient than complicated appliances. 
An excellent instrument, however, for this purpose, 

Fig. 32. 




has been recently invented by Dr. C. C. Thomas Fig. 
32 will give a correct idea of this instrument. 

Filling ivithFoil. — If nonadhesive gold is employed, 
it should be formed into blocks, by cutting from four 
to eight thicknesses into strips one fourth wider than 
the cavity is deep, and rolling them on a broach suit- 
able for the purpose, into cylindrical blocks corres- 
ponding in size with the cavity to be filled, and 
varying not only in size, but in form and density. 
The blocks first to be introduced should be largest, 
followed by those diminishing in size, till the last 



174 



CLASSIFICATION OF DECAYED CAVITIES. 



portions should be very small. dense, conical rolls. 
Where there is an inward or an outward inclination 
of the walls of the cavity, the first blocks should be 
cone-shaped. For introducing the blocks, the plug- 
ging pliers will be required. The first block is taken 
up with this instrument, and placed against the pos- 
terior wall of the cavity with one end on the bottom 
and the other protruding from the orifice, and there 
compressed firmly to its place with the appropriate 
condensing instrument; and, unless there is some 
special retaining point, it may be necessary to hold it 
in its position with a second instrument, till the next 
portion is added. As the successive blocks are intro- 
duced, each is to be thoroughly consolidated, so as to 
be wholly immovable. The filling is to proceed from 
the posterior walls to the center. After the cavity 
has thus been filled up to the center, commence in 
the same manner at the anterior wall, consolidating 
from there back toward the center again, and con- 
densing the last blocks by forcing in at their side a 
small sharp-pointed instrument : the final portion in- 
troduced will be the small, dense, conical roll already 
mentioned. The gold being all introduced, a fine 
square-pointed instrument condenses the projecting 
portion of the filling till it is perfectly solid, when it 
is rubbed down with a rough instrument, and then 
finished with a file, stone, and burnisher, in the 
manner already described. The particular shape of 



FILLING BY CLASSES AND MODIFICATIONS. 175 

the surface of the filling will be suggested by the 
form of the antagonizing tooth. If there is nothing 
to prevent, the surface should be slightly convex ; but 
if there are cusps striking upon the center of the 
crown, concave. 

For dressing down the filling when a concave sur- 
face is required, the instrument represented in Fig. 
33 is very efficient. It consists of a spherical file, 

Fiff. 33. 



finely cut, and on a proper shaft or handle ; and may 
be used in the manner of the ordinary bur drill. A 
variety of sizes, at least four, should be at hand, in 
order to operate properly upon fillings of various sizes. 
Adhesive Foil. — For the purpose of filling these 
cavities with adhesive foil, definite retaining points 
must be formed in them. The gold, prepared in the 
manner already described, is taken up with a serrate- 
pointed plugger, introduced into the retaining point 
or points, and there fixed ; it is then built across 
from one to the other, and over the floor of the 
cavity, till this is completely covered, and then up 
from the bottom to the orifice. When a portion of 
gold is taken on the point of the instrument, the pre- 
cise spot at which to deposit it should be selected, 



176 CLASSIFICATION OF DECAYED CAVITIES. 

and there it should be placed, and, by the first press- 
ure of the instrument, fixed immovably ; a few sub- 
sequent strokes of the instrument close about the first 
point of attachment, will be required. These strokes 
should be close, because if the instrument is lifted up 
and pressed upon the piece at a distance from the 
first point of contact, the attachment is liable thus to 
be broken up. In constructing the filling, we con- 
sider it preferable to keep it built up a little higher 
all around next the walls than at the center, for the 
reason that a more complete adaptation of the gold 
can thus be made, than by any other plan. Some, 
however, advocate the opposite practice ; that is, of 
keeping the filling higher in the center than at the 
walls, and thus forming an angular space into which 
to crowd the gold; because they think that the gold 
is thus kept in more thorough contact with the walls 
of the cavity; and they object to the other practice, 
that, to add and consolidate the gold to the center, 
while the edges are left higher, tends to draw them 
from the walls. This objection, however, has no 
force, if the gold is thoroughly consolidated as it is 
introduced. 

The cavity is thus filled up, consolidated, and fin- 
ished in the usual manner. In adding the last por- 
tions of gold, great care should be taken to make a 
perfect border to the filling. Crystal gold may be 
very advantageously used as a foundation for adhe- 



FILLING BY CLASSES AND MODIFICATIONS. 177 

sive-foil fillings, as it will retain its position perfectly 
in a cavity, where adhesive foil would not. 

Crystal Gold. — The method of filling this class of 
cavities with crystal gold is very simple. The ma- 
terial should be annealed just before its use, and then 
cut or broken into blocks corresponding with the size 
of the cavity to be filled : many small pieces will be 
required to fill up interstices or angles, and they 
may be used as large as will freely enter the cavity. 
The filling may be commenced at the bottom of the 
cavity, and built up from that to the orifice, the same 
plan being followed in adapting it to the walls as 
with adhesive foil, the pieces being passed into the 
cavity with either the plugging pliers, or a serrate- 
pointed condensing instrument. Each piece should 
be thoroughly consolidated before an other is added. 
For condensing the filling next to the walls, a small 
double-pointed or wedge-shaped instrument is valua- 
ble. In all cases where there is a divergence of the 
anterior wall, much care is required in order to make 
a perfect filling ; and too much care can not be exer- 
cised in perfecting the filling round the border of the 
cavity. In condensing adhesive foil or crystal gold, 
the force may be applied almost exclusively in a line 
with the axis of the tooth ; and this is always prefer- 
able to lateral pressure. 

1st Mod. — Extension of decay along one or more 
crown fissures. In a case of this kind, the central 



178 



CLASSIFICATION OF DECAYED CAVITIES. 



cavity is first to be opened and excavated, according 
to the principles already announced. Decay in the 
fissures is in some cases an extension of this central 
decay, and at the point of its termination there will 
be found an acute angle ; but in others, it will be the 
effect of an equal attack all along the fissure, or of 
an extension from some other point than the central 
cavity. This modification of decay may terminate 
not only in an acute angle, but also in an expansion. 

These decayed fissures should be opened up by 
cutting away any projecting portion of enamel, and 
the cavities formed with a small chisel-shaped instru- 
ment, beginning at the juncture of the fissure with 
the main cavity, and cutting clown to the bottom of 
the decay in the manner of a mortise, thus oblitera- 
ting the entire fissure and the acute angle at its ter- 
mination — the latter an important consideration. In 
case there is a very considerable expansion of decay 
at the termination of the fissure, the bur drill may be 
introduced into it, and the rest of the fissure cut out, 
as the character of the decay may indicate. 

If blocks are used to fill these cavities, they should 
be set in and compressed against the end of the 
fissure, protruding from it sufficiently to admit of a 
proper finish ; and block after block then added, till 
the fissure is filled up to the main cavity. Where 
there are two or three of these decayed fissures in 
one tooth, it may be quite as much as can be done at 



FILLING BY CLASSES AND MODIFICATIONS. 179 

one sitting, to fill them, the main cavity being left 
for an other time. In such cases, the filling intro- 
duced at the first sitting, should then be consolidated 
and burnished, so that it may not absorb moisture 
till the main cavity is filled, as already described. 
Much care should be exercised to prevent the gold 
from overlapping the enamel at the sides of these 
fissures. In filling this modification with crystal 
gold or annealed foil, it is better to begin at the 
bottom of the cavity and build up to the orifice, first 
completing the fissure, as we have already described, 
and afterward the main cavity. 

2d Mod. — Two cavities on the same crown in close 
proximity. The thickness of the portion of tooth 
intervening between two cavities on the grinding sur- 
face of the same crown, is determined by the extent 
of the decay ; and the form of it, by the form of the 
cavities; and these two qualities will suggest the 
method of operation. If this intervening portion is 
thin throughout, and devoid of vitality, it should be 
cut away, and the two cavities formed into one ; but 
if it is thick within, though it may be thin at the 
surface, the cavities should be filled separately. In 
some cases it is proper to leave a part of it standing, 
as a sort of ridge between the cavities, though not as 
a definite partition ; in which cases, the filling would 
be begun as in two cavities, and finished as in one. 
In no case, however, when the tooth is living, should 



180 



CLASSIFICATION OF DECAYED CAVITIES. 



this intervening portion remain, if its vitality is gone. 
The details of the process of filling crown cavities, 
have already been indicated. 

Second Class. — Buccal and palatal cavities of the 
molars and bicuspids, and labial and palatal cavities 
of the canines and incisors. In the molars, this class 
of decay begins either at the margin of the gum, in 
the form of a transverse groove, or along the vertical 
depression on the buccal surface of the tooth, or at 
its termination. These groovelike decays, extending 
along the side of the tooth at or near the margin of 
the gum, are ordinarily not very deep; but they 
burrow considerably under the enamel, particularly 
at the side next the grinding surface. In preparing 
these cavities, the projecting portion of the enamel 
must be mostly cut away, leaving them but slightly 
larger within than at the orifice. These grooves, at 
their ends, are shallow ; but in their preparation for 
filling, they should be cut as deep at the ends as 
elsewhere, and, when the main part of the cavity is 
comparatively shallow, deeper. 

The method of introducing gold in the form of 
blocks into these cavities, is, to set in the first block 
at the posterior part of the cavity, and consolidate 
it, and so one block after an other, till the cavity is 
nearly full; and then proceed in like manner with 
the anterior end, back toward the middle, the blocks, 
of course, being permitted to protrude sufficiently for 



FILLING BY CLASSES AND MODIFICATIONS. 181 

the purposes of a finish. For filling with crystal gold 
or adhesive foil, the method is, to form pits at the 
end of the groove, into which the gold is consolidated, 
and built across from one to the other, and then up 
from the bottom to the orifice, when it is finished as 
usual. Care is requisite to prevent the gold from 
overlapping the tooth. 

Those cavities of this class, which are formed in 
the depressions of the buccal portions of the teeth, 
are more easily filled. Often a simple round cavity 
is formed, which may be entirely prepared with a 
bur drill. The method of filling these cavities will 
be readily inferred from the remarks before made. 
If, however, the decay extends along the depressions, 
making a groovelike cavity, this should be filled by 
commencing the introduction of the gold at that side 
of the cavity next the gum. 

1st Mod. — Decay at or near the neck of the tooth, 
and partially or wholly overlapped by the free border 
of the gum. In this modification, the gum is a great 
obstacle to the various steps in the process of filling : 
it is liable to be wounded and to bleed at every 
touch ; it exudes mucus constantly ; and it conducts 
saliva to the parts with great facility. To obviate 
these difficulties, the gum must be removed somewhat 
from the cavity, before the filling is practicable. 
This removal of the free margin of the gum, may be 
made either by cutting away, or by pressing away 



182 CLASSIFICATION OF DECAYED CAVITIES. 

with' pledgets of cotton or other appropriate substance 
placed in the cavity and overfilling it, so as to induce 
a partial absorption of the gum pressed upon, in a few 
days. The former method, however, accomplishes 
the object at once : some good hemostatic, or cautery, 
as nitrate of silver or chlorid of zinc, is all that is 
then necessary to render the filling immediately 
practicable. By means of the cautery, the exudation 
is checked — which, where there is much mucus eli- 
minated, is an important item — and also such a sur- 
face is given to the part, that it will not so readily 
conduct the saliva. It is, perhaps, preferable in many 
cases to cut away this free margin, so that it shall 
not be in contact with the filling after the operation 
is completed. 

After this preparation, the cavity is formed and 
filled as usual. The napkins and paper are to be 
placed in the precise position, and carefully retained 
there. Two or three thicknesses of paper should be 
laid on the gum up to the margin of the cavity, and 
kept there during the process of filling, so as to ex- 
clude all moisture. In filling cavities of the buccal 
portions of the denies sapientice, peculiar difficulties are 
met with : the deca}^ is frequently found two thirds 
covered by the gum ; the muscles of the cheek, thick 
and rigid, lie close against the side of the tooth; and, 
in most cases of this kind, the view, at best, is but 
partial. In operating upon these cavities, an instru- 



/ 



FILLING BY CLASSES AND MODIFICATIONS. 183 

ment for holding out the cheeks is required. (See 
Fig. 29.) 

Third Class. — Anterior proximal cavities of the 
molars and bicuspids. This class of cavities in teeth 
with short, broad crowns, takes place at their necks ; 
but in those with long crowns, and with a diameter 
less at the neck than at the masticating surface, it 
begins at some distance from the neck, toward the 
crown surface, or at the first point of contact of the 
crowns; in which case the teeth ordinarily require 
separation. The method and extent of this will be 
determined by circumstances. If all the neighboring 
teeth stand in contact, it can not be accomplished by 
pressure ; but, if a tooth has been extracted in the 
vicinity, or there are natural spaces between the 
others, it can be, either in whole or in part. When, 
however, the teeth stand close together, they must in 
such case be separated wholly with the chisel and 
file. If but one is decayed, the cutting should be 
exclusively from that. If two are alike affected on 
their proximal surfaces, it should be mostly from the 
posterior surface of the anterior tooth, and should 
leave a space in the form of a V. There should be 
no shoulder left at the neck of the tooth, but the cut 
surface should be plain from the crown to its termina- 
tion at or near the neck. The interval should be large 
enough to enable the operator to manipulate with facil- 
ity, and to see as directly as possible into the cavity. 



184 



CLASSIFICATION OF DECAYED CAVITIES. 



Cjavities of this class are various in form; and they 
require much skill in their excavation and formation. 
Great care is to be exercised not to leave any portion 
of decay in them. By a fatal oversight, decayed 
dentine is often permitted to remain on that side 
next to the neck of the tooth ; and we have seen 
fillings that in other respects were good, very defi- 
cient here ; so deficient, indeed, that a sharp instru- 
ment would readily penetrate the softened dentine 
above them, or even pass between the filling and the 
wall of the cavity. The removal of the decay from 
the cervical walls of all proximal cavities is an im- 
portant particular, neglect of which occasions thous- 
ands of failures. This class of cavities at this point 
should be most thoroughly filled ; for it is a point 
more vulnerable than any other, on account of the 
facility with which foreign substances are here lodged 
and retained. 

In the formation of these cavities, the cervical wall 
should be made to incline slightly inward, and the 
lateral walls, if the tooth will bear the loss, made at 
least parallel with each other ; but if that would im- 
pair its strength, grooves or pits may be made upon 
them for this purpose at proper points. When these 
cavities are large, the dentine is usually all decayed 
in that part of the cavity next to the masticating 
surface of the tooth; in which case, the enamel there 
would constitute the outside of the cavity's upper 



FILLING BY CLASSES AND MODIFICATIONS. 185 

wall; and in such case no cutting in that part is 
admissible. 

Great pains must be taken to arrange and dispose 
the napkins and bibulous paper so as to protect the 
cavity from moisture during the process of filling. A 
roll of paper should be placed on each side of the 
tooth, and on the paper the napkin, properly folded, 
should be laid, and kept in place by the operator 
with the left hand, or by the patient with the specu- 
lum. The gum between the teeth is liable to secrete 
mucus enough to moisten the work, or to be touched 
by the instrument so as to bleed; and to obviate 
these difficulties, a small piece of soft wood should be 
wedged down between the teeth below the cavity, so 
as to press the gum out of the way, and thus provide 
against both contingencies. 

In addition to these preparations, it will, in many 
cases, be necessary to place a cork between the jaws, 
in order to keep them apart during the operation. 
By this arrangement the mouth being propped open, 
the soft parts are sustained more in repose, and so 
less saliva is eliminated from them to interfere with 
the work. 

With this preliminary, the cavity is ready for the 
filling, which is introduced, if in blocks, as before de- 
tailed, beginning with the cervical wall. The caution 
may here again be urged, not to let the gold overlap 
the tooth, particularly at the cervical wall. In filling 



186 CLASSIFICATION OF DECAYED CAVITIES. 

with crystal gold or adhesive foil, special retaining 
points will be required in this wall, two being gen- 
erally sufficient, one toward the outer, and the other 
toward the inner lateral wall, on which walls, too, 
grooves may be made, if the walls are thick enough 
to admit of it. If, however, these walls are not 
parallel, and will not admit of grooves, the crown 
and the cervical wall should be so shaped as to retain 
the filling. But in 'some cases the attachment of the 
filling is made entirely at the cervical wall ; and best 
by means of three pits, bored with the square-pointed 
drill, at different angles, and in such directions as not 
to interfere with the pulp. This kind of attachment 
will serve only for adhesive gold, which is to be very 
thoroughly consolidated into the pits, and built very 
firmly across from one to the other, making little 
projections, which are so many anchors for fastening 
the filling. 

2d Mod. — Decay involving a portion of the masti- 
cating surface. There are two methods of filling this 
modification. One is, to cut down the tooth or the 
projecting angles, and make a plain, oblique border to 
the cavity, and then fill up flush with this border. 
The filling will thus exhibit a single, uniform surface, 
at a considerable angle with the axis of the tooth. 
When a portion of the crown breaks down in conse- 
quence of proximal decay, it is toward the center of 
the tooth; usually the inner and outer corners re- 



FILLING BY CLASSES AND MODIFICATIONS. 1ST 

main. If these projections are feeble and liable to 
be broken away, they should be cut down, and the 
cavity filled as before described. If, however, they 
are firm, they may remain, and the cavity, properly 
formed, may be filled so as almost to restore the 
tooth's original form. This method is seldom appli- 
cable to the bicuspids, but is often available in filling 
the molars. Nonadhesive foil is not adaptable to this 
kind of filling, as it can not be built in so as to with- 
stand the pressure of mastication. A free space is to 
be left between the filling and the adjoining tooth. 

Fourth Class. — Proximal cavities of the incisors 
and canines. If the teeth are not in a corroded con- 
dition, and the file is not required by the strength of 
the decay, separation may be made by pressure, if 
there are no forbidding circumstances; but if the 
cavity is large, and the walls are thin, separate with 
a thin chisel and file. Much has been said as to the 
manner of separating these teeth, some recommend- 
ing that the separation be larger at the palatine part 
than at the labial ; others, that it be larger at the 
points than at the necks of the teeth ; some, that a 
shoulder be left at the necks ; and others, that there 
be no shoulder at all. In making these separations, 
however, the operator must be governed somewhat 
by circumstances, no general rule being applicable to 
all cases. The form of the teeth and the extent of 
the decay will modify the form of the space between 



188 



CLASSIFICATION OF DECAYED CAVITIES. 



them. If the inner wall is thin or broken away, it 
should be cut off more than the outer ; in which case, 
the palatine portion of the separation will be the 
largest — as, indeed, some prefer to make it in all 
cases, performing then the remainder of the operation 
from the inside. But this is a disadvantageous 
method ; for the cavity is more difficult of access from 
within than from without, and the view is less per- 
fect, unless aided by a mirror, the 'use of which is 
always attended with inconvenience : it is preferable 
to make the separation so that the principal part of 
the work can be done from the front. 

In some cases, separation will be larger at the 
points of the teeth than elsewhere ; as, where there 
has been a partial fracture at the points. In cutting 
away, to make the separation, no shoulder should be 
left at the neck of the tooth ; any projection of that 
kind is always objectionable : it is not protected by 
the filling; foreign substances lodge upon and adhere 
to it, and, becoming vitiated, render it very liable to 
decay. The cutting should always extend entirely 
beyond the decay, but only far enough to make a 
perfectly plain border to all the cavity, and should 
terminate without any projection. It is highly im- 
portant, in separating the anterior teeth, to make as 
little alteration as possible in their form. But the 
preservation of the tooth should not be jeopardized 
for the sake of maintaining the integrity of its 



FILLING BY CLASSES AND MODIFICATIONS. 189 

natural form. The first consideration should be, to 
obtain a space sufficient for the purposes of a perfect 
operation ; the second, to have the walls and border 
of the cavity in such a condition that an efficient 
filling can be made ; and the form and beauty of the 
tooth may be reckoned the third consideration. 

The excavation of these cavities requires very deli- 
cate and skillful manipulation, since they are very 
readily injured hy cutting too much or at a wrong 
point. All decayed and discolored portions must be 
entirety removed, as well for the appearance of the 
tooth, as for the permanency of the operation ; after 
which, the cavity is to be formed with great care. 
At the point of the tooth the dentine often has all 
been displaced by decay, leaving only the two plates 
of enamel joined at the edge, and thus forming an 
acute angle, the obliteration of which is always 
attended with risk, unless great care is exercised ; 
and it is very difficult perfectly to fill a very acute 
angle. The inclination of the inner and the outer 
wall of the cavity will depend on its size : when this 
is small or medium, they may be parallel, or, if 
necessary, slightly divergent; but when large, it is 
better not to cut much of the healthy dentine from 
them, lest they be thus weakened. Small grooves, 
however, are admissible on these walls, near the 
bottom of the cavity, when they incline to the center, 
and are generally, in such case, to be preferred to 



190 CLASSIFICATION OF DECAYED CAVITIES. 

pits. More cutting is allowable on the cervical wall 
than elsewhere, as there is no danger here of weak- 
ening the tooth by excavation. In filling with 
adhesive gold, we may, if necessary, rely exclusively 
on this part of the cavity for the retention of the 
plug; and the best method of preparing it is, to make 
two or three little pits in it at different angles, with 
a fine, square-pointed drill. An other method is, to 
form two pits, and make a groove from one to the 
other. Some operators prepare these cavities by 
making pits in each of the walls. This, however, is 
unnecessary, if the cervical wall is properly prepared. 

The cavity being prepared, the rolls of bibulous 
paper or napkin should be placed on the gum inside, 
and between the gum and the lip ; and if the former 
has been wounded between the teeth, or if it elimi- 
nates mucus, a small piece of soft wood or of rubber 
should be crowded down upon it below the cavity. 
The gold, prepared as already described, should then 
be introduced with a small plugger serrated with four 
points, and somewhat flattened about a line above the 
point, so as to be freely used when introduced into 
the cavity. The gold is taken up on the point of 
this plugger, and condensed in the pits of the cervical 
wall; which being completely filled, and the gold 
extending from one to the other, the foundation is 
ready for the remainder of the filling. 

Great care is requisite, in packing the gold into 



FILLING BY CLASSES AND MODIFICATIONS. 191 

these cavities, perfectly to adapt and adjust it to all 
their points, so as to insure its thorough contact with 
every part of their interior. If the form of the tooth 
has been measurably retained, and the border of the 
cavity is even, the surface of the plug should, when 
finished, be slightly convex ; and, in introducing the 
filling, reference should be had to this particular. 
The cavity may be filled up two thirds of the way to 
the wall next the point of the tooth, and then its re- 
maining portion filled from the point back to the 
preceding filling; or, what is probably better, begun 
at the bottom and filled to the surface, and then 
finished in the usual manner. 

For filling these cavities with nonadhesive foil, the 
special retaining points already described are not re- 
quired ; but the cervical wall of the cavity is slightly 
cut under, and the lateral walls so shaped as to 
secure the filling in place. These cavities are in 
some cases very difficult to fill with nonadhesive foil, 
whether in the form of blocks or otherwise, especially 
where they are large, with the walls inclined to the 
center, and the tooth bone friable. To force a wedge- 
shaped instrument into these fillings, for the purpose 
of condensing them, is inadmissible, since there is 
thus great danger of breaking the walls of the cavity, 
and, in many cases, of moving the filling from its 
place. 

1st Mod. — The palatal wall broken away. Fract- 



192 



CLASSIFICATION OF DECAYED CAVITIES. 



ures of this kind assume different forms ; sometimes 
triangular, extending from the border of the cavity 
toward the center of the tooth, and terminating in an 
acute angle; and sometimes the border of the cavity 
is broken away irregularly, or so as to form part of a 
circle. When a triangular notch is broken out of 
the wall, the operation of filling may be performed in 
one of two ways : If the portions of the wall remain- 
ing at each side of the fracture are thick and firm, 
they may be left, and the cavity may be rilled up 
flush with both the proximal and the palatal surface 
of the tooth, the latter being thus restored with gold 
to the extent of the fracture or notch. If, however, 
the remaining portions of the wall are frail, they 
should be cut away till a border is reached suffi- 
ciently firm to sustain the filling. Such cutting will 
leave the notch of a circular form, and, in many 
cases, will remove almost the whole of the inner wall 
of the cavity. As the decay extends toward the 
center of the tooth, owing to the concavity of its 
palatal surface, this wall becomes very thin ; but, in 
all cases, the excavation should be such as to leave a 
definite wall, though it be but slight, all along that 
part of the cavity. In such a case, good retaining 
points must be made in the cervical wall, since the 
permanency of the filling will depend almost entirely 
upon these. 

The surface of the filling, when finished, may be 



FILLING BY CLASSES AND MODIFICATIONS. 193 

slightly convex from one lateral wall to the other ; 
the palatal portion of the surface, from the point of 
the tooth to its neck, will partake of the curvature of 
the border of the palatal wall ; but the anterior por- 
tion will be only flush with the anterior wall. Much 
care is requisite to give these fillings a perfect finish, 
on account of the irregularity of surface, this, in many 
instances, being both convex and concave. As a 
material for filling these cavities, adhesive gold is 
much to be preferred. Indeed, in many of them, it 
is impossible, with nonadhesive gold, to make a per- 
fect filling, because they have no general embracing 
form. In such cases, the filling should be introduced 
from the palatal side of the tooth. 

2d Mod. — The labial wall of the cavity broken. 
The fractures of this wall are of various forms, and 
of extents corresponding with the friability of the 
enamel. There is sometimes the triangular notch, 
extending far toward the middle of the tooth; and 
sometimes there are two or three small notches ; and 
still in other cases, almost the whole of the wall will 
be broken away from the point to the neck. When 
there is simply a notch in the enamel, it is important 
for the appearance of the tooth, to fill it up; and 
when there is any prospect of success, the remaining 
portion of the wall being retained, the operation is to 
be performed as already described for the palatal 
wall. It will, however, in many cases, be necessary 



194 CLASSIFICATION OF DECAYED CAVITIES. 

to -cut away part of the remaining portions of the 
wall, leaving the general form of the border some- 
what circular; though the notch form, in some in- 
stances, is not wholly obliterated. 

In filling this kind of cavity, it is desirable to re- 
store as much as possible the form of the tooth. The 
rilling should be built out from the border of the wall 
almost to a line with the tooth's original proportions, 
so that the whole surface of the filling will be con- 
vex ; and should be finished with great care, the 
stipple finish being preferable for that part exposed 
to view. 

3d Mod. — The cavity extending almost to the point 
of the tooth, and terminating, or cropping out, at the 
surface. In the preparation of this cavity, that part 
next the point of the tooth, should be cut in enough 
to form a definite wall there, and to give room for 
sufficient thickness and strength in that portion of 
the plug. Many operators attempt to fill this kind 
of cavity without such precaution, terminating that 
part of the plug in a thin, sharp edge. The method 
is very objectionable ; for this thin edge will get more 
or less separated from the tooth, and foreign sub- 
stances will be forced under it, and, becoming vitiated, 
induce decay. Indeed, a defect of this kind is a sure 
precursor of the destruction of the filling. The intro- 
duction and finish of the filling in this kind of cavity 
are the same as first described for this class ; and the 



FILLING BY CLASSES AND MODIFICATIONS. 195 

admonition may be repeated, that there be left no 
thin overlappings of the filling, that may become 
changed in position. 

kill Mod. — The cavity large, and the lateral walls 
thin and friable. In this kind of cavity, the dentine 
is almost entirely removed from the lateral walls, 
leaving little else than the enamel after the excava- 
tion of the decay. These walls will, of course, admit 
of no cutting for the purpose of giving them a more 
desirable form. The cervical wall must be shaped 
with special reference to a retention of the filling, to 
consolidate which the requisite pressure must be 
applied almost exclusively toward this wall. It 
requires extreme care to condense the gold in cavities 
of this kind, and adapt it to the lateral walls, without 
fracturing them ; and various methods have been sug- 
gested to prevent such an accident. Pluggers with 
very fine points are recommended, as consolidating 
the gold with much less pressure than would be 
necessary with large-pointed instruments. But it has 
been maintained that a perfect adaptation of the gold 
to the inner parts of these walls is not important, 
provided the adaptation at the border is perfect. It 
is certain, however, that a filling thus imperfectly 
adapted, is not so good as though the gold were in 
contact with all points of the cavity; and besides, the 
liability of fracturing the wall, is just as great in con- 
solidating at the border as within. The walls may 



196 CLASSIFICATION OF DECAYED CAVITIES. 

be sustained by enveloping the tooth to the borders 
of the cavity with some material perfectly adaptable 
to it, and capable of resisting the force applied in the 
process of consolidation ; as, gutta percha or plaster 
of Paris. If the former is employed, it should be 
softened by warming, moulded upon the tooth, and 
then permitted to harden. The hardening may be 
facilitated by throwing cold water on it from a 
syringe. It is then to be trimmed even with the 
border of the cavity, so as to admit the filling. If 
plaster of Paris is used, it should be the best article. 
Yet gutta percha is to be preferred. But a better 
protection than either may be made of cheoplastic 
metal, taking an impression of the tooth, and from 
that moulding the shield ; and this material is always 
to be recommended in extreme cases. In these fill- 
ings, when the enamel is clear and translucent, the 
gold will be visible through it. To obviate this 
difficulty, some appropriate substance may be placed 
between the outer wall and the gold — some sub- 
stance that will restore the natural color of the tooth. 
Quill, horn, paper, and asbestos have each been em- 
ployed for this purpose. Horn is, perhaps, the best 
material, as it can generally be selected of a suitable 
color. A thin lamina of this may be obtained by 
pounding a piece of the horn for a few moments, 
till a layer is detached; which may then be dressed 
down to the proper size, softened in warm water, and 



FILLING BY CLASSES AND MODIFICATIONS. 197 

placed in the cavity next to the outer wall, yet so as 
not to extend quite to the border. The presence of 
this substance makes the operation of filling a little 
more complicated ; but the horn, being softened, is 
easily pressed to the side of the cavity and conformed 
to it; and it may be made to retain its place, when 
first introduced, by touching it at one or two points 
with some adhesive material ; or it may be made very 
soft, adjusted in the cavity, and then conformed com- 
pletely to the wall by a temporary filling of gutta 
percha, which, after having chilled and stiffened, may 
be removed, leaving the horn thoroughly adapted and 
ready for the gold. 

Fifth Class. — Posterior proximal cavities of the 
molars and bicuspids. These are separated like 
anterior proximal cavities, except that, ordinarily, to 
open them up, more is to be cut from the tooth, on 
account of the greater difficulty of approaching and 
inspecting the cavity. The same general principles 
are applicable to the opening of this class of cavities, 
as to that of the third class, except that pressure can 
not be as frequently employed, since the cavity will 
not be as well exposed by this as by cutting, nor 
rendered so easy of approach. Indeed, in operating 
on these cavities, the use of the mirror is often neces- 
sary, it being impossible to obtain a direct view into 
them, after having cut away all that it is admissible 
to remove. The accessibility of these cavities will 



198 CLASSIFICATION OF DECAYED CAVITIES. 

depend on circumstances ; such as the location of the 
tooth, its inclination, the size of the mouth, the flexi- 
bility of the muscles, and the ability of the patient to 
open the mouth and keep it open. Generally, in 
operating on these cavities, for the removal of decay, 
the formation, and the filling, curved instruments 
will be required; but their curvature should not be 
greater than the necessity of the case demands. 

The cavity, during its preparation, must be fre- 
quently examined. Its general form, and the size, 
kind, and location of the retaining-points will be the 
same as in class third. The lateral walls, if the 
cavity is not too large, should be made parallel with 
each other; the undercutting at the crown wall will 
be less than in anterior proximal cavities ; and the 
cervical wall should have the same general form as 
in other cases. In this latter there should be made, 
at different angles, pits for retaining-points — three, if 
the tooth is a molar, and two if a bicuspid. For 
making these pits, Merry's drill will be found more 
convenient than any other instrument. 

Preparatory to introducing the filling, the same 
appliances should be used to protect the cavity from 
moisture, that have been indicated in modification 
first of class third. Crystal gold makes a better be- 
ginning for these fillings than foil: and hence the 
retaining-points should be filled up with it, and an 
attachment made from one to the other; on which 



FILLING BY CLASSES AND MODIFICATIONS. 199 

foundation adhesive foil may be built, almost up to 
the crown wall of the cavity, and then the remaining 
portion filled from the bottom to the orifice. These 
fillings should have a single plain surface, which will 
be at a greater or less angle with the axis of the 
tooth, according to the greater or less portion cut 
away in the separation. It is impracticable to build 
these fillings up as some of those in the anterior 
proximal cavities may be, because of the difficulty of 
thoroughly consolidating and finishing their proximal 
portions, especially near the neck of the tooth ; 
though the difficulty is somewhat obviated by placing 
a piece of polished metal, of the proper thickness, 
back of the cavity, against the adjoining tooth, intro- 
ducing the filling, and consolidating it firmly up to 
this piece of metal : the lost portion of the crown 
being thus restored, the metal is then removed, and 
the filling dressed off and finished in the manner de- 
scribed heretofore. The labor, tedium, and difficulty 
of manipulation are increased the farther back in the 
mouth the decay is situated. The modifications of 
this class are the same as those of the third class of 
cavities, and, except the second modification, are sus- 
ceptible of the same methods of filling. 

Special Cases. — The first case that we shall con- 
sider here, consists in a complication of proximal 
decay with decay on the buccal or palatal portion of 
the tooth, thus undercutting one of the crown angles. 



200 CLASSIFICATION OF DECAYED CAVITIES. 

Sometimes these decays are on both sides, in the 
form of transverse grooves, meeting at the corner of 
the tooth. In such cases, if the pendent crown 
angle of the tooth is firm and strong, the cavities 
may be formed in the proper manner, and filled 
without interfering with the masticating portion of 
the tooth at all; but, if the pendent portion is friable, 
it should be cut away, and the corner built up with 
gold. The method of forming the part to be filled 
will depend on the extent of the decay. 'When this 
is large, a greater number of retaining-points will be 
required than when it is small ; and these should be 
located at such parts as will make them most tena- 
cious of the gold, and least subversive of the strength 
of the tooth. The filling may be built up so as to 
restore the original form of the tooth, thus presenting 
three surfaces, the proximal, the buccal or palatal, 
and the masticatory; or, it may be made with a single 
slightly convex surface, adapted and finished most 
completely at all its borders. This kind of filling 
can be made only with adhesive gold. 

The palatal portion of the crown broken away, leav- 
ing the outer portion standing — nerve not exposed. — The 
tooth, in such case, is decaj'ed away so that the floor 
of solid dentine is near the margin of the gum, the 
labial third of the crown still standing. The decay 
having been all removed, four or five little pits 
should be made on this floor, as near its circumfer- 



FILLING BY CLASSES AND MODIFICATIONS. 201 

ence as practicable ; and a small groove may be cut 
from one of these pits to an other all round near the 
edge of the floor. Then two little pits should be 
made at the base of the standing portion of the 
crown, if they can be, without interfering with the 
pulp, provided this is still living. The decayed part 
thus prepared, a sufficient shield, in the form of pa- 
per, folds of napkin, etc., is to be thrown round the 
tooth, to protect it against moisture during a pro- 
tracted operation : in this particular great care is 
necessary. 

For building up a crown of this kind, only adhesive 
gold can be used ; and this should be of the best prep- 
aration, and in the most perfect condition, since it 
is important that the different portions of the filling 
be most thoroughly united. The instruments em- 
ployed in the operation should be of the best kind 
and in the best condition, the serrate points being 
definite and sharp, though not too long : those with 
four, six, or eight points may be advantageously used 
for packing the gold. But care must be exercised 
lest these fine points be turned ; for when that is the 
case, the instrument is liable to displace the portion 
of gold, and thus break up its first attachment during 
the process of consolidation; and when this is broken, 
the piece of gold can not again be made to adhere as 
perfectly as before. 

With every thing thus in readiness, the retaining- 



202 CLASSIFICATION OF DECAYED CAVITIES. 

points are all to be filled, the gold extending from 
one to the other ; which is then to be built all over 
the bottom of the part to be restored, projecting a 
little beyond the periphery, and being perfectly con- 
solidated there, and kept somewhat higher round the 
border than in the center. The gold should be built 
on in this manner till the crown is large enough, 
after dressing, to give the desired size and form. In 
finishing up, the aim should be, to restore as perfectly 
as possible the lost form of the tooth ; the mastica- 
ting surface, the lost cusp, the antagonism, and all. 
The adaptation of the gold, too, to the standing por- 
tion of the crown should be most complete ; imperfec- 
tion in this respect impairs the appearance of the 
work, and jeopardizes the security of the operation. 

Occasionally the crown of a molar tooth is found 
decayed off all round, almost to the margin of the 
gum, the pulp having previously receded so as not 
to be exposed. It is, in such case, desirable to re- 
store the lost portion of the crown, and make a mas- 
ticatory surface such as shall antagonize properly 
with the teeth of the opposite jaw. x\s yet, there is 
no other method of accomplishing this, than by build- 
ing it up with gold — adhesive gold foil or crystal 
gold. In the preparation for this crown of gold, the 
edge should be dressed smooth and even all round 
the tooth ; then six or eight deep pits should be made 
at different angles about on the base thus prepared ; 



FILLING BY CLASSES AND MODIFICATIONS. 203 

and they should be bored with a drill larger than is 
commonly used for retaining-points. These pits may 
be slightly enlarged within. The method of building 
up the crown is just the same as that described for 
building up part of a crown, the pits being first filled, 
then joined together, and the gold extended all over 
the part to be covered by the filling. In extending 
the gold from a retaining-point or points, it is neces- 
sary to build up to a considerable thickness above the 
orifice of the pit. The portion of gold extending 
along on the tooth from the pit, should be quite thick 
and firm, so as not to curl up from its position, on 
the addition of subsequent portions. Every particle 
of gold, indeed, should be so manipulated, that it will 
securely maintain its first position. The permanency 
of the operation will depend very much upon this 
precaution. The gold should extend somewhat be- 
yond the circumference of the tooth all round, in 
order to a thorough adaptation and finish. 

The foundation thus prepared, and kept free from 
moisture, the crown is easily built up by the ordinary 
method of packing the gold. Any desired shape can 
be given to this artificial crown ; but, of course, that 
which most nearly resembles the form of the natural 
crown, is in all cases most nearly perfect. The masti- 
cating surface of this gold crown is to be formed from 
the indications given by the antagonizing teeth. 
Such crowns will wear for years, and perform all the 



204 CLASSIFICATION" OF DECAYED CAVITIES. 

functions of the natural organs. Artificial crowns of 
this kind have been attached to the tooth, by screw- 
ing into the pits small pieces of gold wire at different 
angles, and then building up round and between 
them with the gold foil, on the principle already 
described, thus making these wires serve as so many 
anchors for fastening the work. This, "however, is a 
less efficient method than the one first described, 
since there is no cohesive attachment of the foil to 
these gold anchors, and it is retained in place only 
by the mechanical arrangement of the wires ; but by 
barbing or roughening them, or giving them abrupt 
curves, they may be made to retain the crown well, 
if it is thoroughly consolidated and united. But the 
method of anchoring with foil, as before observed, is 
always to be preferred, since by this there is a weld- 
ing of the entire mass, and an anchorage, too, quite 
sufficient in all cases to retain it iu its place. 

Filling large cavities on the labial surfaces of the 
superior incisors. — These cavities are usually super- 
ficial, and frequently coextensive with a considerable 
part of the surface of the tooth. A method of filling 
them, somewhat novel, though not without merit, has 
recently been introduced to the notice of the profes- 
sion by Dr. Volck, it having been first suggested to 
him, however, by Dr. Maynard. It consists in filling 
up the cavity principally with a piece of enamel, as 
near the color of the tooth as possible. The cavity, 



FILLING BY CLASSES AND MODIFICATIONS. 205 

when nearly round, should be formed with a wheel bur 
of the proper size ; and after having been thus reamed 
out, a slight undercutting should be made all round 
with an excavator. Then a piece of enamel being se- 
lected, it is dressed to a proper thickness, which should 
be slightly greater than the cavity's depth, and to a 
perfectly circular form, its size being such as to let it 
drop, with a little play, into the cavity, and the edge 
of it being beveled from without. For fastening this 
in the cavity, roll a strip of several thicknesses of 
gold foil round its edge, and add as much as can be 
forced in with it; set it all in place in the cavity, 
and then condense the gold down into the groove all 
round with a thin-pointed plugger, more gold being 
added, if necessary, to fill the groove completely full. 
Afterwards, with the file, stone, and burnisher, dress 
off the whole to a proper level with the surrounding 
tooth, finishing very carefully with the burnisher. 
The unsightliness of a large gold filling on a front 
tooth is thus obviated, no metal except that compo- 
sing the ring of attachment in the groove being ex- 
posed to view. It is a beautiful operation, and one 
whose successful accomplishment will require con- 
siderable constructive talent and skill. 



CHAPTER VIII. 

PATHOLOGICAL CONDITIONS. 

Hitherto, in our consideration of the treatment of 
caries, we have postponed the subject of the vitality 
and pathology of the teeth altogether. It now re- 
mains to describe the diseased conditions to which 
the teeth are subject, and the treatment which those 
respective conditions indicate. This is an important 
department of the practice, since upon skill in this, 
as well as upon the manner of performing the work, 
the success of the operation depends. 

Premising that our remarks on this branch of the 
subject are predicated on the fact admitted, that the 
teeth possess vitality, we proceed to consider the 
pathological conditions to which, in common with all 
organic matter, they are liable. There is but one 
diseased condition of living dentine that presents any 
considerable difficulty in the ordinary operation of 
filling teeth, and that is, inflammation, or exalted 
sensibility. This condition was referred to in the 
remarks on the treatment of caries, as being one that 



PATHOLOGICAL CONDITIONS. 207 

most generally accompanies decays of the teeth. 
Whether or not this affection is real inflammation, is 
a point that has been considerably controverted ; and 
the assertion has been made, that it is of no conse- 
quence whether it is or not, provided we understand 
the true method of treating it. This, however, is 
not to be so readily conceded ; for the confession that 
we do not know what to call a thing, generally im- 
plies an ignorance of its character and phenomena : 
while the term inflammation conveys a definite 
notion, the phrase exalted sensibility is very vague 
in meaning. That it is true inflammation, is the 
opinion of our best dental writers. The dentine is 
endowed with the functions of absorption, nutrition, 
and secretion — characteristics that always imply a 
susceptibility of inflammation. In inflammation of 
the soft parts, there are present various indications ; 
as, pain, redness, swelling, and increased heat. But 
in dentine, on account of its peculiar structure, all 
these indications can not be manifested : for instance, 
redness, since the red globules do not circulate 
through it ; nor swelling, since the structure is too 
dense ; nor perceptibly increased heat, since the circu- 
lation is of too low a grade. But, one of the most 
definite indications of inflammation, namely, exalted 
sensibility, is present here in all its force. And there 
are various other circumstances that indicate this 
condition to be real inflammation : the same irri- 



208 PATHOLOGICAL CONDITIONS. 

tating causes that induce inflammation in the more 
highly organized parts, occasion it in the living den- 
tine ; this condition of the teeth is always affected by 
a general inflammatory diathesis, and their sensitive- 
ness, when there is this general tendency to inflam- 
mation, is always increased, and local treatment in 
such case will commonly be inefficient ; a modifica- 
tion of such a condition of the system produces a 
very corresponding change in the affected teeth ; and 
those remedial agents which are employed in the 
topical treatment of inflammation elsewhere, are suc- 
cessfully used in the treatment of inflamed dentine. 
From all these circumstances, the conclusion is almost 
irresistible, that this affection of the teeth is a real 
inflammation. 

As it has been already remarked, the only definite 
and direct indication of inflammation of the dentine, 
is exalted sensibility ; though this is not an immedi- 
ate consequence of that condition, independent of 
external circumstances ; for the pain resulting directly 
from inflammation in the soft parts, is not experi- 
enced here, by reason of the low grade of vitality and 
the feeble circulation. But the teeth, in a state of 
inflammation, will suffer pain when subjected to sud- 
den variations of temperature, whether induced by 
the air, by fluids, or by any hard substance ; and 
when subjected to the influence of agents that irri- 
tate the nerve-tissue anywhere, such as acids, some 



PATHOLOGICAL CONDITIONS. 209 

alkalies, salts, and sweets. In regard to degree, 
extent, and location, this affection exhibits a variety 
of manifestations ; in degree, from the most mild to 
the most intense — sometimes fixed at a uniform pitch 
of pain, and sometimes passing through the gamut of 
torture up to the most acute anguish. The character 
of the affection is modified by differences in the 
organic structure of the teeth, those most vascular 
and most highly organized being most readily and 
most extensively involved; and therefore the teeth 
of the young are generally more liable to it than 
those of the old. So, too, persons of a plethoric or a 
strumous habit, as well as those in a febrile condi- 
tion, are peculiarly predisposed to this affection. 
Sometimes irritation or disturbance of other organs of 
the system, sympathetically or secondarily induce 
inflammation of the dentine. Uterine irritation fre- 
quently does so ; and hence, during pregnancy or a 
protracted suppression of the catamenia, the teeth are 
very liable to be thus affected, and, if decayed, to 
become very sensitive. 

Inflammation of the dentine will sometimes be 
exhibited in various degrees in different teeth in the 
same mouth at one time. This is owing to differ- 
ences in the organic structure of teeth developed at 
different periods of life, to differences of their loca- 
tion in the mouth,, and to differences of exposure to 
those agencies which are apt to induce the condition. 



210 PATHOLOGICAL CONDITIONS. 

As to the extent of this inflammation, it ma}' be con- 
fined to a thin lamina of bone immediately beneath 
the decomposed portion, or may extend deep into the 
body of the tooth, and, indeed, in some cases, pervade 
the dentine of the entire crown. This latter extent, 
however, it is not likely to have, unless it* is the 
result of a general predisposition : if it is produced 
by local causes, it will not, in general, penetrate very 
deeply into the dentine. Most commonly, the great- 
est sensitiveness is at the union of the dentine with 
the enamel ; but. sometimes, it is confined to a small 
point within the cavity, either because there is a 
concentration of nerve-fibrils there, or because there 
has been a determination of the irritating influences 
to that point — the former being the most probable 
cause. The greatest sensitiveness, as already re- 
marked, is generally at the surface of the dentine, 
because that is the termination of the nerve-fibrils 
which ramify the dentine, and wherever nerve-fiber 
terminates, there always we may look for exalted 
sensibility. Hence it is, that decay of the teeth is 
often found to be more sensitive in its incipient 
stages, than when it has become more advanced. 

Treatment of Inflamed Dentine. — There are several 
methods of treatment that might be employed to 
remedy this condition. In many cases, where time 
and circumstances will permit, a removal of all irri- 
tating agents from the affected parts, will enable 



PATHOLOGICAL CONDITIONS. 211 

nature alone to effect a restoration to health. All 
decomposed dentine is to be cleaned from the cavity, 
every exciting influence in it withdrawn or neutral- 
ized, and the cavity itself perfectly filled with some 
nonconducting material, so as entirely to exclude all 
foreign substances. This material may be gutta 
perch a or Hill's Stopping ; — and this, in the property 
of nonconduction, is superior to any other ; — or, in 
some cases, it may be tin or gold ; but, when either 
of these is employed for the purpose of such tempo- 
rary filling, some nonconducting substance should be 
placed between it and the sensitive dentine. The 
length of time necessary for a restoration of the 
affected part, under this treatment, will be much 
varied by circumstances. The cases susceptible of 
this kind of treatment are those in which there is no 
constitutional predisposition, in which the vitality is 
strong, and the recuperative power vigorous. When 
the temporary fillings are made of metals, the patient 
should be careful to protect them from sudden changes 
of temperature. For such fillings, in case they are 
required but for a short time, a lock of cotton satu- 
rated with a solution of gutta percha and chloroform, 
may be used. 

But, in cases in which the vitality is low, the 
affection chronic, the exciting cause highly irritating, 
and the general diathesis inflammatory, nature, un- 
aided, will not effect a cure. In such circumstances, 



212 PATHOLOGICAL CONDITIONS. 

therapeutic treatment is indicated. The agents em- 
ployed in topical treatment may be divided into two 
classes : first, resolvents, or those which have for 
their object an entire restoration to health of the 
part affected ; and second, escharotics, or those which 
have for their object the death of a portion or all of 
the diseased part. The former class of agents is of 
course preferable, when their object can be promptly 
accomplished by their use, and especially preferable 
to those agents which endanger the vitality of the 
whole tooth. In very many cases in which topical 
applications are indicated, constitutional treatment is 
also required ; and this should be of an antiphlogistic 
character. The immediately adjacent parts, too, as 
the gums, the mucous membrane, etc., should be 
carefully regarded. Indeed, treatment of the gums 
by counter irritation, depletion, and various prepara- 
tions, such as the conditions may indicate, will often 
be found prerequisite to a successful treatment of sens- 
itive dentine by topical applications. 

There are very few agents used simply as resolv- 
ents. The properties characteristic of this class of 
agents are tonic, stimulant, sedative, and astringent. 
Tincture of capsicum may fitly represent the stimu- 
lant, Peruvian bark the tonic and astringent, gum 
myrrh the tonic, and opiates the sedative principle. 
Astringents, stimulants, and sedatives all tend to 
counteract the inflammation. The agents of this 



PATHOLOGICAL CONDITIONS. 213 

class are not very extensively used in the treatment 
of dentine, not because they are not ultimately effi- 
cient, but because their action is less vigorous than 
that of some other agents. When, however, time 
and circumstances will permit, mild treatment, if effi- 
cient, is to be preferred. 

But there are many cases in which, for want of 
time, something more rapid in its action is required. 
Of this character is the second class of therapeutic 
agents, namely, escharotics, or those which, by their 
action, destroy a portion of the tissue with which 
they come in contact. It may be well to notice, 
separately, the preparations commonly used for this 
purpose. 

Tannin, or Tannic Acid. — This is the active prin- 
ciple of vegetable astringents, and is found most 
abundant in nutgalls. It unites with albumen, fibrin, 
and gelatin, forming with them insoluble tannates. 
Its medicinal influence is almost necessarily topical, 
since the promptness of its action on albuminous sub- 
stances, and the insolubility of its compounds with 
them, prevent its admission into the general circula- 
tion. The action of tannin on dentine has been 
already explained. Either its aqueous or its alcoholic 
solution may be employed, the latter being the better 
and more convenient preparation. Where tannin is 
applied to dentine, there is formed a tannate of albu- 
men, which, being insoluble, protects from irritation, 



214 PATHOLOGICAL CONDITIONS. 

and probably incites to healthy condition, the living 
parts beneath it. 

Creosote, or Carbolic Acid. — Formerly, creosote was 
obtained by distillation of wood, and differed some- 
what from that in present use, which is prepared by 
distillation of coal tar — this latter being the genuine 
carbolic acid. It dissolves freely in alcohol or ether, 
and sparingly in water ; and its action may therefore 
be modified by dilution. Creosote produces -its caustic 
effects by its affinity for albumen and gelatin, with 
which it forms insoluble compounds; and from its 
modus operandi, it is evident that the popular opinion 
that it promotes decay of the teeth, is an error. 

Nitrate of Silver. — This salt is a powerful caustic, 
whether applied to soft parts or to bony tissue. Its 
action is somewhat complex. Nitric acid is liberated 
by the decomposition of the salt, when in contact with 
organic matter. Nitrate of silver has a strong affinity 
for albumen, uniting with it without difficulty ; and 
the compound thus formed, is soluble in nitric acid or 
in a dilution of chlorid of sodium. When the nitrate 
is applied to the skin, the immediate result is a 
whitish mark, caused by a union of the salt with the 
albumen of the cuticle ; but this soon turns black, by 
the reduction of the salt and the decomposition of the 
silver ; when, for each atom of silver set free, there is 
liberated an equivalent of nitric acid. There is here, 
then, an agent that acts promptly on the gelatinous 



PATHOLOGICAL CONDITIONS. 215 

portion of the tooth, destroying its vitality to the ex- 
tent of the combination which takes place, and that, 
by the decomposition of part of the salt, and the con- 
sequent liberation of part of the acid, also acts with 
energy on the calcareous portion. The compound 
formed by the nitrate with the organic constituents 
of the tooth, is insoluble except with a few substances, 
and therefore protects the subjacent parts; and the 
precipitation of the reduced oxyd on the surface, 
affords some additional protection. The insolubility 
of the compound above mentioned, prevents an ab- 
sorption of the nitrate by the dentine, and renders 
its action necessarily superficial. When the nitrate 
is neutralized by a union with it of an equivalent of 
the constituents of the dentine, no further chemical 
action is possible. The compound formed by this 
union is soluble in a dilution of the nitrate ; and if 
this be applied in too great a quantity, there may be 
a larger loss of substance than is desirable or at all 
necessary ; for, as long as free nitrate remains in 
solution in the cavity, the insoluble compound is not 
precipitated, and the surface is therefore exposed to 
the continued action. It is preferable to employ the 
nitrate in the solid state, or, when this is not practi- 
cable, in a concentrated solution and small quantity, 
rather than in a copious dilution and repeated appli- 
cation. 

From the observations already made, it is quite 



216 PATHOLOGICAL CONDITIONS. 

evident that no harm can result to the tooth from a 
proper application of this agent, beyond the portion 
of it immediately acted upon. The nitrate can not 
be absorbed by dentine, but it stimulates the sub- 
jacent dentine to more healthy action ; though some 
maintain that it is not as efficient in this respect as 
some proper chlorid. It acts to a greater depth than 
tannin or creosote, but not so deep as chlorid of zinc, 
nor with so much pain. 

Chlorid of Zinc. — This is more generally used in 
the treatment of sensitive dentine than any other 
caustic. It exerts an antiseptic and disinfectant, as 
well as an escharotic influence. In its operation it 
decomposes, the chlorine affinitizing with the animal 
and the calcareous elements of the dentine. It is 
milder in solution than in solid, and less efficient and 
less painful. It is soluble in water, alcohol, ether, or 
chloroform. The etherial and the chloroformal solu- 
tions are, in their action, least painful of all the forms 
in which this chlorid is applied. The union of this 
agent with the gelatinous constituent of the tooth is 
also more prompt in solution than in solid. The 
ether and the chloroform may lessen the pain by 
their anesthetic influence. In the use of the chlorid 
or any other active caustic, it is important to bear in 
mind the exalted vitality which follows its applica- 
tion ; and the operation should be immediately per- 
formed. In the teeth of young persons, or those in 



PATHOLOGICAL CONDITIONS. 217 

which the animal constituent greatly predominates, 
the vitality will be more promptly aroused than in 
those of an opposite texture, and the change, too, will 
be greater. If the inflammation is confined to a thin 
lamina, it will be almost instantly allayed by the 
application of the chlorid, and the cavity may be ex- 
cavated, as though there had never been any exalted 
sensibility ; but if the operation be delayed any con- 
siderable time, the tooth will often be found in a 
worse condition for excavating than before the appli- 
cation. The remarks on absorption under the head 
of nitrate of silver, apply with equal force here: there 
is not the least danger from this source; indeed, there 
can be none, even when the chlorid is applied to the 
soft parts. 

Ter chlorid of Gold. — Of this preparation the ethe- 
rial solution only has been employed. This acts with 
great promptness on the dentine, forming an insoluble 
compound with the gelatinous elements, and the 
chlorine of it forming also a combination with the cal- 
careous portion. On account of the promptness with 
which this agent operates, neither the pain nor the 
disturbance of the subjacent parts caused by it, is 
great. This substance is very liable to decompo- 
sition. By exposure to air or light, the gold is pre- 
cipitated in the metallic form. But, protected from 
these, it may be preserved for a long time. This 
agent will not be absorbed by the dentine. 






218 



PATHOLOGICAL CONDITIONS. 



Arsenious Acid. — The modus operandi of this agent 
is involved in great obscurity. In regard to its topical 
action, Professor Bache, says : " Arsenious acid, when 
it produces the death of a part, does not act, strictly 
speaking, as an escharotic ; it destroys the vitality of 
the organized structure, and its decomposition is the 
consequence. The true escharotic acts chemically, 
producing a decomposition of the part to which it is 
applied; a state incompatible with life." Pereira 
says : " Though employed as a caustic, yet the nature 
of its chemical influence on the animal tissue, is un- 
known ; hence it is termed by some a dynamic caus- 
tic." Its escharotic power certainly bears no propor- 
tion to its vitality ; but it is probable that it forms defi- 
nite compounds with some of the constituents of living 
tissue ; and if so, these compounds appear to be readily 
and rapidly decomposed, so that the acid becomes 
again free to attack, with similar results, the sub- 
jacent parts. The topical application of arsenic is 
liable to be followed by constitutional effects. 

All dentists are aware of the fact that a tooth-pulp 
may be destroyed by arsenic, through a wall of con- 
siderable thickness. To accomplish this, the agent 
must in some way penetrate the substance of the 
dentine ; and the vitality of the dentine is destroyed 
so far as it is thus penetrated ; indeed, the vitality of 
the whole crown of the tooth, both dentine and pulp, 
is often destroyed by the use of this remedy, applied 



PATHOLOGICAL CONDITIONS. 219 

even to a small cavity. Exalted sensibility of den- 
tine is subdued by this agent, more through its vital, 
than through its chemical energy. It is very soluble 
in creosotes and all similar oils, and, to a considerable 
extent, in alcohol and water. It is absorbed much 
more rapidly in solution than in solid ; and the more 
vascular the dentine, the more rapid and extensive 
will be the absorption ; and on this account there is 
great risk in applying it to the teeth of young persons, 
or to any teeth that are highly vascular ; indeed, it 
will, in some cases, destroy the vitality of very dense 
teeth. The manner in which it passes into the den- 
tine, is not very definitely understood. It is very 
certain, however, that in more highly organized 
parts, it is carried through by the circulation, and 
also may be taken up by imbibition. In either of 
these ways it may pass into the dentine, and so far as 
concerns the results, it matters not in which way. It 
is enough to know that there are well defined cases 
of its specific effect on the constitution, after having 
been applied to toothbone — demonstrating that it 
must have been taken up by the circulation ; and 
also cases of its manifest effect on the periosteum in 
a short time after having been applied to the cavity 
of a tooth, the pulp of which is dead — thus proving 
that it must have been absorbed by imbibition. 

If arsenic is ever employed in the treatment of 
sensitive dentine, it should be suffered to remain in 



220 PATHOLOGICAL CONDITIONS. 

the cavity but a short time — from one to three hours 
— and then the part with which it was in contact, 
should be very thoroughly excavated ; and in de- 
ciding in what cases it is proper to use it, there is 
need of careful discrimination as to the tooth's struct- 
ure and density; for injurious results have some- 
times followed its application, notwithstanding the 
utmost care : if it has once been absorbed by the 
dentine, antidotes will avail nothing. On the whole, 
therefore, it is probably better to refrain from its use 
altogether in the treatment of sensitive dentine. 

Alkaline caustics have been, to some extent, used 
for the treatment of this affection. A preparation 
made after the following formula, is said to relieve 
some cases very promptly : take Canada balsam and 
slacked lime, and, having made them into a paste, 
fill the cavity partially full with it, and permit it to 
remain until the object is accomplished. 

The sensitiveness of dentine may be obtunded by 
thorough friction on the affected part with a smooth 
burnisher. This method, however, is applicable only 
to those cases in which there is room to use the in- 
strument. On the surfaces of the teeth, where there 
may be sensitiveness, it is very applicable and very 
efficient. Simple pressure, without friction, it is sug- 
gested, will accomplish the same object; though press- 
ure and friction combined, are doubtless more effi- 
cient. 



CHAPTER IX. 

EXPOSED PULPS. 

Usually, when the pulps of the teeth are exposed, 
it is in consequence of decay, but sometimes of a 
gradual wearing-down of the organs in mastication. 
When the pulp of a tooth is found exposed, the 
course of remedy to be pursued, will be directed by 
the following considerations : — 

1st. The constitution and the vital energy of the 
system. 

2d. The condition of the mouth and teeth. 

3d. The condition of the pulp. 

4th. The size of the orifice at which it is exposed. 

5th. Whether the exposure is of recent, or of 
remote origin. 

6th. If in a tooth of more than one fang. 

7th. The position of the tooth in the mouth, and 
that of the decayed cavity in the tooth. 

The propriety of attempting to preserve the vital- 
ity of the pulp after exposure, has been questioned. 
Some take the position that after the development 
and formation of the tooth, the pulp is no longer of 



222 EXPOSED PULPS. 

any use, and may, without damage, be dispensed 
with ; while others maintain that, when the pulp of 
a tooth is destroyed, the tooth is no longer of any 
value. The truth is, perhaps, a medium between 
these extremes. The pulp of the tooth is valuable 
in the economy, or nature would dispense with it. 
Analogy teaches that it would not be retained longer 
than it could subserve some beneficial purpose. But 
it is also true, that a tooth may be valuable for a 
long time after the destruction of its pulp, notwith- 
standing it is in a less perfect condition ; though it is 
always desirable perfectly to preserve the life of the 
tooth ; for the crown depends on the pulp for its vital- 
ity, and living dentine opposes more resistance to 
decay than dead; besides, a dead tooth never pre- 
sents the bright, lifelike appearance of a living one. 
The parts about a dead tooth, too, are far more liable 
to disease than those about a living one. These are 
only a few of the prominent arguments for retaining 
the nerves of the teeth. • 

It has been maintained that the structure of the 
tooth-pulp is of such peculiar character, and so sus- 
ceptible of diseased action, that after it has become 
affected, though but slightly, it can not be restored 
to a healthy condition. We see no ground, however, 
for such an assumption, except it be in the imperfect 
treatment which this organ so frequently receives; 
for the fact of its delicate structure does not neces- 



EXPOSED PULPS. 223 

sarily imply an impossibility of restoring it from 
disease. The pulp of the tooth is endowed with 
such functions as ordinarily render living tissue sus- 
ceptible of treatment for abnormal conditions; as 
circulation, nutrition, absorption, and a distribution 
of nerves. The success attending the methods of 
treating exposed pulp, practised by the dental profes- 
sion during the last few years, is a source of more 
encouragement than a thousand theories. 

Treatment of Exposed Pulps. — In cases where the 
conditions are favorable, — the constitution good, the 
pulp but recently exposed at a small orifice, and in a 
healthy condition, treatment may be instituted with 
considerable certainty of success. If there is no in- 
flammation or irritation, therapeutic treatment is not 
indicated ; but the decay should be removed and the 
cavity formed without wounding the pulp, if possible; 
though a slight wound is of no serious consequence ; 
for immediately after the hemorrhage ceases, the 
operation may proceed as though the pulp were 
intact. There have been suggested various methods 
for protecting the pulp in cases of this kind : for- 
merly, the capping of nerves was very extensively 
practised; by which a shield was thrown over the 
pulp, so as to prevent the filling from coming in con- 
tact with it. Various materials have been suggested 
for caps; but gold and lead have been chiefly used 
for the purpose, especially when the object was to 



224 EXPOSED PULPS. 

form an arch over the point of exposure. These 
caps are cut out of thin gold plate, or thick sheet 
lead, of the proper shape and size, and stamped with 
a convex punch, thus receiving such a concavity as 
fits them for covering the exposed pulp without 
touching it. A little groove, of depth sufficient to 
hold the cap and prevent it from being displaced by 
the introduction of the filling, may be made in the 
dentine all round the orifice of exposure. The cap is 
then to be adjusted to its position in the cavity, hav- 
ing been previously touched round its edge with 
adhesive wax, and the filling to be introduced in the 
usual manner, carefully, so as not to displace the 
cap ; and if this is of lead, great caution is to be 
observed in condensing the filling above it, since it 
will be easily compressed. 

The therapeutic influence of lead on exposed 
nerves is supposed by some to be definite and de- 
cided ; but, though lead is a less perfect conductor of 
heat, and in this respect is better than gold, and 
though, in the capacity of a pulp-cap, its indestructi- 
bility is probably quite sufficient, yet, if no change 
takes place in it, it is not very apparent how it exer- 
cises any therapeutic action on the pulp. Experi- 
ence, however, proves that the success is quite as 
good in the use of lead caps as in that of gold ; and 
the former are much more easily formed. 

There is an other method of shielding an exposed 



EXPOSED PULPS. 225 

pulp, which is, to form an arch over it by the filling. 
This operation is performed by beginning the filling 
at that side of the cavity most easily approached, 
building on the gold from the bottom to the orifice, 
up almost to the point at which the pulp is exposed, 
and then attaching the pieces of gold to the prece- 
ding part, without permitting them to come in contact 
with the pulp, interposing a fine burnished point 
between this and each piece as it is introduced, and 
thus giving a smooth surface to that portion of the 
filling next the nerve. "When, by this process, the 
filling has been extended beyond the point of expo- 
sure, it may be dropped down on the body of the 
dentine, and finished in the usual manner. This 
method of forming a protection over a tooth-pulp, 
possesses no advantage over the ordinary cap ; and 
being much more difficult, it is impracticable in any 
but skillful hands. 

This practice with exposed nerves, however, has, 
within the last few years, been almost wholly aban- 
doned, and for these two reasons : because it so fre- 
quently failed to accomplish the object, and because 
a better method of treatment has been discovered. 
It was found that, under that practice, many cases 
which at first promised well, failed to preserve the 
life of the pulp ; though the fatal results were not 
always immediate, a year or two, and, in some in- 
stances, a much longer period, intervening between 



226 EXPOSED PULPS. 

the operation and the death of the tooth. In favor- 
able' cases, the pulp, even after exposure, will, if pro- 
tected from the influence of foreign substances, throw 
out a bony deposit, and even close up an orifice of 
exposure, thus forming for itself a natural shield. It 
is submitted that the capping operation is not the 
best protection for facilitating this process. It is 
probable that, in some cases, the space between the 
cap and the pulp, though it were large, would be 
filled with coagulable lymph; yet, even- if it were 
thus filled, this lymph might not be formed into bony 
tissue ; and if it were not, it could not fail ultimately 
to prove injurious to the pulp. But if the space 
should not be filled with lymph, the difficulty would 
be equally as great, since the pulp would protrude 
through into the vacuum beneath the cap, and neces- 
sarily become diseased, since it would be irritated by 
its contact with, and its pressure against, the sharp 
edges of dentine at the orifice of the cavity ; and it- 
may remain thus diseased for a long time, or die at 
once. Thus it is, no doubt, that the great majority 
of failures occur under this kind of treatment. In 
order to obviate this difficulty, it has been suggested 
that the space under the cap be filled with some 
appropriate substance, as a thick solution of gutta 
percha and chloroform, or a small pledget of cotton 
saturated with collodion. 

The frequent failures which occur in capping 



EXPOSED PULPS. 227 

nerves, have incited the profession to seek some other 
method of treatment. A vacuum above the nerve 
being objectionable, some suitable material is employed 
as a shield for this, being placed on the orifice of ex- 
posure, in contact with the nerve ; and the filling is 
then introduced without any pressure upon the point 
of exposure. There are several substances that have 
been thus employed, the chief of which are asbestos, 
oiled silk, collodion, gutta percha, and horn. The 
material for this purpose should be a nonconductor of 
heat, should not be subject to decomposition when in 
contact with the pulp, and should present a smooth 
surface and be easily adapted. In shielding a nerve 
in this manner, it is important that pressure be not 
made upon it; and there is not much liability to this, 
where the orifice of exposure is small ; but, where it 
is large, much care is required in the introduction and 
consolidation of the plug. The opinion has been 
entertained by some, that the pulp of a tooth will 
not tolerate any foreign substance in contact with it ; 
but facts refute such an opinion. By this kind of 
protection for a nerve, secondary dentine is more 
likely to be developed. 

A very perfect covering for an exposed pulp may 
be made by dropping on it a little collodion or solu- 
tion of gutta percha, and then, after the evaporation 
of the ether or chloroform, filling over it. This 
method has the advantage of completely filling and 



228 EXPOSED PULPS. 

occupying the space, and exactly conforming the fill- 
ing to the part. When the exposure is at a large 
orifice, if the pulp is healthy, and the constitution of 
the patient good, the same general course of treat- 
ment may be adopted, except that more care and 
skill will be necessary in the performance of an opera- 
tion. Indeed, it is difficult to make a good operation 
in cases of this kind, using for the covering only a 
soft or a very flexible material. 

A method of operating, that is probably more effi- 
cient than any other, is, to prepare the cavity a? 
already directed, place on the pulp two or three drops 
of collodion or solution of gutta percha, letting it 
partially stiffen, and then over this fit a gold cap as 
exactly as possible, so that it shall rest on the solid 
dentine far enough from the orifice of exposure to 
preclude it from injurious influence on the pulp. On 
this, the filling is introduced as usual, care being had 
not to displace the cap, which, in all such cases, 
should have a seat made for it, adapted at the time 
of the preparation of the cavity. 

When the pulp of a tooth becomes, by exposure, 
inflamed or diseased, some more special treatment is 
indicated, and usually it is therapeutic. In every 
such case, the treatment will contemplate two objects: 
the preservation of the pulp, when the circumstances 
will warrant; and when they will not, then its de- 
struction. The former of course is always to be pre- 



EXPOSED PULPS. 229 

ferred, where practicable. Some of our best operators 
very strongly denounce that wholesale destruction of 
the pulps of teeth, practised by many ; while some 
dentists never attempt to restore them to health at 
all, however slightly diseased. This, as elsewhere 
intimated, is erroneous practice ; for there is no obvi- 
ous reason why the pulp of a tooth may not be re- 
stored from disease to health as readily as other parts, 
endowed, as it is, with circulation, nutrition, absorp- 
tion, and the distribution of nerves. The particular 
kind of treatment required in any given case, how- 
ever, will be controlled by various circumstances; 
such as the nature and extent of the disease ; whether 
it is of chronic or acute type ; and when the irrita- 
tion, or inflammation, is but slight, and is kept up 
solely by the contact of irritating substances, restora- 
tion of the pulp may be effected by a removal of these 
irritating causes, and a protection of the pulp against 
their further influence : in such case, nature, unaided, 
effects the restoration. In default of a vigorous con- 
stitution, the pulp, though but slightly affected, will 
require topical therapeutic treatment; and meanwhile 
general treatment may be employed to give increased 
tone to the system. In the local treatment, neutral- 
izing agents should be applied first, and afterwards 
such as will counteract and reduce inflammation, 
especially if this is in an active state. But if the 
pulp is in a morbid condition, with retarded circula- 



230 EXPOSED PULPS. 

tion, and a tendency to enlargement, very active and 
stimulating applications will be indicated, and in 
some cases escharotics, such as nitrate of silver and 
chlorid of zinc, the latter especially where there is a 
tendency to prurient enlargement of the pulp. Four 
therapeutic principles, namely, astringents, - tonics, 
stimulants, and escharotics, are mainly to be relied 
upon in the topical treatment of exposed pulp ; but 
a detailed account of the nature, influence and effects 
of all the individual agents embodying these prin- 
ciples, and of the respective methods of applying 
them, belongs rather to dental therapeutics. 

The length of time requisite for the treatment of 
exposed pulp, will vary with different cases. In the 
case of a recent acute inflammation, the process of 
restoration may be completed in two or three days ; 
while, in other cases, where the difficulty is of long- 
standing and of a more complex character, it will re- 
quire from a week to two months. Leeching and 
countering tation of the gums are sometimes resorted 
to in this treatment.; but it is rare that any definite 
beneficial result ensues. Depletion of the pulp itself 
may often be practised with decided success : and it 
may be accomplished either by puncturing the pulp 
with a fine-pointed instrument, or by excising a small 
portion of it at the orifice of exposure with a very 
sharp one, in either case avoiding any laceration of 
the pulp. By this means the distended vessels are 



EXPOSED PULPS. 231 

relieved ; and in many cases, where the difficulty is 
but slight, immediately after such relief by punctur- 
ing, so soon as the hemorrhage has ceased, the tooth 
may be filled. But if the depletion is by excision, 
time must be allowed — ordinarily from three to ten 
days. 

The formation of secondary dentine, by which the 
orifice of exposure is closed up, has already been re- 
ferred to ; and it has been suggested that treatment 
to facilitate this process may be instituted. With a 
view to this, temporary fillings are sometimes intro- 
duced ; and irritation of the pulp by frequent slight 
friction, has been adopted ; but the success attending 
this treatment is not very manifest. If a shield of 
secondary dentine is desirable before permanent fill- 
ing, the best method of securing it, is, after seeing 
that the general recuperative power is in the best 
condition, to place in the cavity a temporary filling, 
of such material and in such manner as shall be least 
offensive to the pulp, and then leave nature to accom- 
plish the work. In many cases, especially in young 
persons, this process would be facilitated by an ad- 
ministration of bone phosphate. The pulps of the 
teeth of the young are more difficult to treat success- 
fully than those of the more advanced in life. 

Destruction of the Pulp. — There are cases in which 
an attempt to restore the pulp, even when recently 
and but slightly diseased, would prove unavailing : 



232 EXPOSED PULPS. 

so feeble is the vitality that it is destroyed at almost 
the 'first touch. Two cases in apparently the same 
condition pathologically, but in different constitu- 
tions, will, under the same treatment, exhibit very 
different results. A pulp that is highly diseased, is 
but seldom, if ever, under any circumstances, sus- 
ceptible of restoration; and in such case, of course, 
destruction is indicated. This was formerly supposed 
to be an impracticable operation, for two reasons : 
first, because it was very difficult and painful ; and 
second, because of the consequences likely to ensue. 
Then, the operation was attempted only on teeth of 
one fang, and those of cylindrical form ; but now, it 
is performed successfully on all classes of teeth. 
When destruction of the pulp is decided upon, such 
means should be employed as will effect the object 
promptly and thoroughly. Every thing should be 
entirely removed from the pulp-chamber and the 
canal of the fang ; for any remaining portion is liable 
to inflammation and suppuration ; and alveolar ab- 
scess, too, frequently ensues. 

There are two methods of destroying the pulp : the 
one, by an operation ; the other, by a therapeutic 
application. The choice of these methods will be 
governed by circumstances; such as the temperament 
of the patient, the condition of the tooth and parts 
about it, the class of the tooth to be operated upon. 
For patients of a nervous, irritable temperament, to 



EXPOSED PULPS. ' 233 

whom a removal of the pulp by an operation would 
occasion great pain and a severe shock, it would be 
better to apply some agent to destroy the vitality 
of the pulp, and then remove it; but, on the con- 
trary, where there is vigor, a capacity of endurance, 
it is preferable to remove the pulp at once by an 
operation. To accomplish this, there are two or 
three methods of manipulation. In the first place, 
however, by whatever method it is removed, it 
should be fully exposed ; the orifice of exposure 
should be as large as the pulp-chamber, and the en- 
trance as nearly as possible on a line with the tooth's 
axis; hence it will be necessary in many cases to 
make an opening into the pulp-chamber at a point 
different from that of the opening caused by the 
decay. For instance, in the incisor teeth, when the 
decayed cavity is small on the side near the margin 
of the gum, penetrating to the nerve-chamber, and 
exposing the pulp, the entrance through this opening 
into the canal will be almost at right angles with it ; 
and in such case it would be impossible, through this 
opening, to manipulate freely in the fang ; and it 
would be necessary to make an opening with a drill 
through the palatal portion of the tooth directly into 
the canal; which opening should be large enough 
readily to allow of a removal of the pulp through it, 
and of an unimpeded performance of all the subse- 
quent operation on the canal of the fang. 



234 EXPOSED PULPS. 

After the pulp has been thus exposed, the instru- 
ment should be selected for its removal. There are 
different forms of instruments for this purpose. Some 
operators employ the untempered, four-sided, barbed 
broach, thrusting it up into the canal as far as pos- 
sible, then twirling it two or three times around, and 
thus wrapping the nerve round the instrument; when 
both are drawn away together. This method always 
occasions considerable pain. Others employ simply 
the three- or four-sided broach, thrusting -it through 
the pulp all the way up the canal, and thus lacera- 
ting it and breaking up its structure, so that it may 
afterward be removed without much pain. An other 
very awkward and bungling method is, to force up 
into the canal a piece of wood adapted to the size of 
the space, and thus drive the pulp before it all the 
way. Of all the methods of destroying the pulp, this 
is the most objectionable, and should never be em- 
ployed. An other method, and the one which seems 
preferable to all others, is as follows : take a very 
fine ud tempered steel wire, round and smooth, not 
larger than 34 to 36 of Stub's gaugeplate ; flatten 
the extreme point, and turn it to an angle of from 
thirty to forty degrees ; place the edge of this against 
one wall of the canal at the point of exposure of the 
pulp; press it steadily up the canal, with its edge 
bearing against the wall, as far as it will go, and then 
twirl it suddenly round : thus an excision is effected 



EXPOSED PULPS. 235 

near the point of the fang, when the pulp with the 
instrument may be drawn away together ; or, if not 
thus drawn, it may be caught with some fine point, 
and removed without pain. This manner of intro- 
ducing the instrument, too, causes less pain than 
either of the others ; for there are no sharp edges or 
points presented in passing the instrument up the 
canal, to cut or lacerate the pulp. In the removal of 
the pulp from the teeth of young persons, care should 
be taken lest the instrument pass entirely through 
the foramen, at the apex of the fang ; but with 
adults, there is little or no danger of such an accident. 
The directions given here would be quite sufficient, 
if closely followed, for the removal of the pulps of 
the six anterior superior teeth. In order to the re- 
moval of the pulp from the bicuspids, the entrance 
can ordinarily be effected through the decayed cavity. 
Usually, there is some lateral compression of the 
fangs of these teeth ; and the canal through the fang 
partakes of the formation, so that it represents a 
mere fissure expanded a little on each side of the 
center. It is often difficult, and requires very deli- 
cate manipulation, to remove all the pulp from these 
fissures : a very fine instrument may be pressed down 
each side, and yet a portion of the pulp remain in 
the center. This difficulty is most fully presented in 
those cases in which there has been an apparent, 
though abortive, effort of nature to produce two fangs. 



236 



EXPOSED PULPS. 



The removal of the pulp of the molar teeth is a 
more extensive and complicated operation. The 
pulp to be operated upon should be fully exposed, 
the orifice of exposure being made as nearly as pos- 
sible of the size of the pulp-chamber ; and the instru- 
ment to be used, should be such as last described, 
except that it should be much larger, and is to be 
introduced, in the same manner, to the bottom of the 
pulp-chamber, and rotated suddenly, so as to cut off 
the ramifications of the pulp into the fangs, thus at 
one sweep dislodging the entire body of it without 
laceration. The practice of plunging a large barbed 
or cutting instrument into the pulp of a molar tooth, 
is barbarous in the extreme. The branches of the 
pulp in the fangs should be removed in the manner 
already directed for the removal of the pulps from 
teeth of single fangs. The palatal fang is very easily 
operated upon ; but, as to the buccal fang, there is 
frequently encountered the same difficulty referred to 
in speaking of the bicuspids. Commonly, when a 
pulp is removed in this manner, the wound of exci- 
sion heals by first intention, and there is formed a 
permanent cicatrice. 

Actual Cautery. — Formerly, for destroying tooth- 
pulp, the actual cautery was employed to a consider- 
able extent, and was at one time a favorite method 
with French dentists. This consists in heating a 
wire of proper size to a white heat, and thrusting it 



EXPOSED PULPS. 237 

up the canal of the fang to the apex, the object being 
to destroy the pulp the instant the wire comes in 
contact with it. The operation requires much skill, 
and is attended with many difficulties. It is fraught 
with terror to the patient ; if the temperature of the 
wire is not at the white heat at the time of its inser- 
tion, the pain of the operation is most intense ; it is 
liable to leave the parts in such a condition as often 
to induce inflammation and suppuration, which may 
involve the investing membrane and the surrounding 
parts. Besides, by this method, the object is, at 
best, no more successfully attained than by others. 

Potential Cautery. — This term is applied to those 
therapeutic agents which destroy vital tissue by estab- 
lishing a condition incompatible with vitality. Many 
preparations have been employed as topical applica- 
tions to destroy the pulps of teeth, but only two or 
three to any considerable extent. A consideration 
of the nature and specific action of these agents may 
not here be out of place ; and, first, of 

Arsenious Acid. — This has been more used, topi- 
cally, for the destruction of tooth-pulp, than all the 
other applications. The first account we have of its 
use for this purpose, dates back to 1836, when it was 
applied by Dr. Spooner, though others claim to have 
employed it at about the same time. The specific 
action of arsenious acid on vital tissue is not well 
understood. It is supposed by some that it forms a 



r 



238 EXPOSED PULPS. 

compound with some element of the tissue, and in 
this way destroys the vitality. 

Any such combination, however, has hitherto es- 
caped detection; and it is certain that if a compound 
is formed, it is not fixed or permanent in its char- 
acter, since the arsenic will be carried to different 
parts of the system, and its specific influence mani- 
fested wherever it goes ; which could not be the case 
if it formed a fixed compound. The more probable 
theory is, that it destroys vitality by its influence on 
nerve tissue. Animal tissue takes it up by imbibi- 
tion ; and it is also absorbed by the circulation, and 
conveyed by it, as already suggested, throughout the 
system. Frequently, however, it is applied to living 
tissue under conditions that prevent such absorption. 
It is often employed in the treatment of carcinoma. 
In the application of arsenious acid to the pulps of 
teeth, for their destruction, several circumstances are 
to be considered ; such as the age of the patient, the 
constitutional tendency, the vascularity of the den- 
tine. Where the vascularity is great, the utmost 
caution is required. The indiscriminate use of this 
agent in the teeth of the young, is attended with 
great risk. Some constitutions are peculiarly sus- 
ceptible of its influence, experiencing its effects even 
in remote parts of the system, after its application 
only to the pulp of a tooth. It is absorbed more 
readily in solution than in solid. It is very salable 



EXPOSED PULPS. 239 

in creosotes and all the oils of that nature, and some- 
what soluble in alcohol and water. In many cases, 
when it is applied to the pulp of a tooth, more or less 
disturbance of the periosteum is exhibited a short 
time after — in some instances in a few hours, and in 
others after several days ; thus giving evidence that 
it has, by some means, come in contact with the pe- 
riosteum. Its influence on this will often be mani- 
fested under percussion, in advance of any other 
symptoms. 

Application. — There are two or three methods of 
applying arsenious acid for the destruction of the 
pulps of teeth. The ordinary arsenic of commerce is 
used. It was formerly employed very extensively in 
connection with sulphate of morphia, mixed in equal 
parts, and applied to the pulp with a small pledget of 
cotton, moistened with creosote or any other essential 
oil, the former being most frequently used. Alcohol, 
ether, or water may be employed in stead of creosote, 
and in some respects and in some cases would be 
preferable. The pledget of cotton, thus prepared, is 
introduced into the decayed cavity, with the prepara- 
tion in contact with the exposed pulp. An other 
pledget of cotton, saturated with a thick solution of 
gum sandarac and alcohol, or gutta perch a and chlo- 
roform, is placed over this in the cavity, to prevent 
the escape of the preparation, or the entrance of 
moisture or foreign substances : any preparation may 






240 EXPOSED PULPS. 

be used, that will accomplish these objects. In the 
application of the pledget, care must be exercised lest 
too much pressure be made on the pulp, and pain be 
thus produced. In order to prevent this pressure, 
an other method has been adopted, which consists in 
forming a cap of lead, placing in it the arsenic,in the 
dry state or with some suitable solvent, and then fit- 
ting it over the exposed pulp, and retaining it there 
with a pledget of cotton, as above, or with Hill's 
Stopping, gutta percha, or adhesive wax. - Thus the 
preparation comes gently into contact with the pulp, 
and prevents any pressure on it. The morphine is 
used for the purpose of diminishing the pain which 
frequently results from the application of arsenic ; 
but its influence for such a purpose is predicated 
more on theory than on practice ; for facts prove 
that, applied to living tissue, it produces pain rather 
than allays it. Therefore the more observing and 
better class of practitioners have discarded it. 

Other substances have been mixed with arsenic, 
for the purpose of mitigating or altogther relieving 
the deleterious consequences so liable to follow its 
administration; as, for instance, pulverized charcoal, 
which combined with it in equal parts by weight, 
makes a favorite preparation with good practitioners, 
by some of whom it is claimed that the charcoal 
counteracts the specific effect of the arsenic on parts 
other than those for which it is directly designed. 



EXPOSED PULPS. 241 

But this theory, in the light of any elucidation yet 
given, is very vague. The claim can not be, that 
charcoal is an antidote to arsenic, since facts refute 
it ; for if it were such antidote, the arsenic of the 
preparation, when applied to the pulp of a tooth, 
would fail of its effect, because the charcoal, being 
also in contact with the pulp, would there, if ever, 
counteract the poison. But this it does not do; for 
the pulp is destroyed about as readily by this prepa- 
ration as by arsenic alone. And if, when the arsenic 
and charcoal are thus together, no counteracting 
influence of the latter is manifest, much less will 
there be any when the arsenic, escaped from the 
charcoal, runs riot through the organic tissues, 
whither the latter can not follow. The only prob- 
able advantage, then, of this preparation, is, that the 
arsenic is not taken up from it by the tissues so 
rapidly, as when that is applied alone or with any 
thing that is soluble with it ; for, when thus applied, 
the whole is very soon dissolved, and taken up by 
the pulp and dentine. But, when combined with 
charcoal or the like, little more of the arsenic is 
absorbed than that which comes in contact with the 
pulp. Hence the conclusion, that the influence of 
the charcoal is mechanical, and not therapeutic. 

This preparation is better applied perfectly dry, 
beneath a lead cap, which should completely close 
the cavity. Any other material that would mix as 



242 EXPOSED PULPS. 

readily with the arsenic, without being soluble, and 
that' would not induce irritation when in contact with 
the pulp, would be quite as good for this purpose as 
charcoal. Irritating gasses generated in a tightly 
closed cavity, may be absorbed by charcoal. 

Cobalt, in which the active principle is arsenic, has 
been extensively used for destroying nerves ; but it is 
in no respect superior, and in some respects it is prob- 
ably inferior, to the preparation of charcoal and 
arsenic : it is applied in the same manner. - 

The length of time the preparation should remain 
in the tooth, will be determined from the condition 
of the pulp when it is applied, the age of the patient, 
the vascularity of the dentine, the susceptibility of 
the patient to the influence of arsenic, and the like 
circumstances. It will usually be from three to 
twenty four hours. In some cases, a very small par- 
ticle will thoroughly accomplish the work ; while in 
others, a much larger quantity may remain in con- 
tact with the pulp even for a much longer time, 
without producing more than a superficial result. 
And cases occasionally occur, in which it seems 
almost impossible to destroy the vitality of a pulp 
with arsenic. A case is on record, in which the pulp 
was first fairly exposed in a superior bicuspid tooth, 
the health and constitution being good, and the tem- 
perament sanguine-lymphatic ; and arsenic with mor- 
phine was applied to it, directly, five times within 



EXPOSED PULPS. 243 

ten days, without producing any apparent effect ; 
then an application of creosote and tannin was made 
three or four times, during as many days; afterward 
the tooth was temporarily filled with gutta percha ; 
and finally, in ten or twelve days, this filling being 
removed, the pulp appeared in a state of perfect pres- 
ervation and health, with all the indications of un- 
diminished vitality. Over the exposed point there 
was placed a nonconductor, and upon it a filling of 
gold ; and one year after, the tooth presented the 
appearance of perfect life and health, having given 
the patient no annoyance during the whole period. 
Several similar cases might be cited, if it were neces- 
sary. 

Hence it is quite obvious that there is a great di- 
versity of susceptibility to the influence of arsenic, 
and that the study of these idiosyncrasies is both in- 
teresting and valuable. The recurrence of injurious 
consequences from the use of arsenic, has induced 
many operators to abandon it altogether. But these 
injurious results perhaps occur always either through 
maladministration, or from a peculiar susceptibility 
to the influence of the drug ; and a superior skill and 
a more accurate diagnosis would avoid them entirely. 
After the desired result with arsenic, it has been 
thought that antidotes might be made available. 
The hydrated sesquioxyd of iron is one of the best 
antidotes to arsenic, and has been used in the teeth 



244 EXPOSED PULPS. 

to counteract its injurious effects; but it is of no 
avail here ; the arsenic has the start of it, and, in- 
deed, would outstrip it, with an equal start. 

From the foregoing in regard to arsenic as an ap- 
plication for destroying the nerves of teeth, the fol- 
lowing conclusions are justly deducible : it is, in 
general, very efficient; it is a heroic agent; it should, 
in all cases, be used with great caution ; in some 
cases it is entirely inadmissible; a free administration 
of it is liable to be succeeded by bad consequences ; 
and skill, rather than counteracting agents, is to be 
relied upon in its application. 

Filling Palp Cavities and Canals. — After the pulp 
of a tooth has been destroyed, whether by an opera- 
tion or by therapeutic treatment, the part at the 
point of its detachment should, in almost all cases, 
before the filling is introduced, be rendered sound ; if 
possible, a permanent cicatrice should have formed. 
In cases, however, of good constitution and strong 
recuperative power, where a nerve has been removed 
by an operation, the fang may be filled as soon as the 
hemorrhage has ceased ; but such cases rarely occur. 
Generally, the part will require treatment ; and the 
character and duration of this will be determined by 
the circumstances — as, the vital energy of the system, 
and the method employed for the pulp's destruction. 
When this has been effected by an operation, the 
part of detachment is restored to soundness much 



EXPOSED PULPS. 245 

more readily than when by an application of arsenious 
acid, and less topical treatment will ordinarily be re- 
quired ; indeed, in many such cases there will be 
nothing else necessary, than to keep the canal well 
cleansed, so as to obviate any irritation that other- 
wise might be induced by the offensive gasses or fluids 
of decomposition. But it is generally best to employ 
some deodorizing agent, such as chlorid of sodium, in 
these cases. When the pulp has been destroyed by 
arsenious acid, more energetic treatment is usually 
demanded ; for then there is always a greater or less 
disposition to slough or discharge through the tooth ; 
which must of course be entirely abated, before the ope- 
ration of filling is at all admissible. In the treatment 
of this condition, the canal should be kept perfectly 
clean by frequent syringing ; floss silk, moistened with 
some suitable liquid, such as a solution of nitrate of 
silver, or creosote and tannin, should be introduced 
up to the inmost part of the cavity, and should be 
changed every twentyfour hours, the cavity being 
thoroughly washed each time. It will be necessary, 
in many cases, to continue this treatment for several 
days. In order to determine whether the condition 
is such as to admit of the filling, the floss silk should 
be removed after a sufficient time is supposed to have 
elapsed, the cavity thoroughly cleansed and dried, 
and a portion of dry floss or cotton introduced loosely 
into the canal. Then close up the decayed cavity 



■ 



246 



EXPOSED PULPS, 



with adhesive wax, gutta percha, or some other sub- 
stance that will effectually exclude the moisture ; let 
it remain thus from twelve to twenty-four hours; then 
open the cavity, and withdraw the silk or cotton, and 
if this is found free from moisture and odor, the tooth 
is ready to be filled. 

The treatment just described will be sufficient for 
all cases in which the pulp has been destroyed by the 
operator. But teeth whose pulps are already dead, 
would seem to be less difficult of treatment and fill- 
ing; yet they are not so; — indeed, the therapeutic 
treatment of these is usually more protracted, and 
their diseased condition less easily controlled; and 
this because of the fact that the decaying pulp, re- 
maining in the canal, becomes very offensive to the 
living parts adjacent, in which it induces a chronic 
diseased condition, frequently involving the dentine 
along the walls of the canal in decomposition. 

A classification of these teeth, based on their con- 
ditions, might be somewhat auxiliary to a further 
examination of this subject; and the following will 
probably embrace them all : — 

1st. Those whose pulps are dead, but their remain- 
ing parts alive and healthy. 

2d. Those predisposed to disease. 

3d. Those already diseased, either discharging 
acrid matter through the fang, or exhibiting inflam- 
mation of the periosteum. 



EXPOSED PULPS. 247 

4th. Those having alveolar abscess. 

Sound or slightly decayed teeth are sometimes 
found with dead pulps. This condition may be pro- 
duced in various ways : by blows, or by any force 
that will partially loosen the tooth ; by undue press- 
ure in filling ; by excessive sensitiveness of the 
dentine, even where the decay is not extensive ; and, 
sometimes, by a filling of the tooth when it is in an 
unfit state for the operation. Ordinarily, in cases in 
which the pulp is dead before its exposure, and there 
is no abscess from the fang or periosteum, the nerve- 
chamber may be opened, and the remains of the pulp 
removed. The canal should then be cleansed out, 
and floss silk saturated with chlorid of sodium, in- 
troduced and permitted to remain from one to six 
hours ; when it should be withdrawn, the pulp-cavity 
and the canal again thoroughly cleansed, and, there 
being no discharge of pus through the fang, it may 
then be filled. The fact that the dead pulp is inclosed 
in its chamber without producing irritation, is evi- 
dence that there is no secretion of pus. Occasion- 
ally, where the pulp has died from exposure, 
the living part immediately adjacent will present a 
healthy condition, and there will be no discharge; 
such cases should be treated in the manner just de- 
scribed. In operating on teeth already dead, more 
delicate manipulation is requisite to prevent irrita- 
tion, than on those in which the pulp is destroyed by 



248 EXPOSED PULPS. 

the operator: In very many cases of dead teeth, 
where there is not a state of actual disease, there is 
a strong predisposition to it ; and in these cases, the 
preparation of a cavity, or the introducing and con- 
densing of a filling, will produce inflammation of the 
periosteum. When such a condition is recognized, 
several sittings may be required to complete the ope- 
ration. But it is not always easy to recognize; yet, 
whenever it is suspected, it is well to press the inves- 
tigation, which may be guided by the following rules : 
ascertain whether the tooth experiences a different 
sensation or any pain, under percussion in any direc- 
tion ; whether periostitis has ever existed in that or 
in a contiguous tooth; whether the parts adjacent to 
the tooth are in a healthy state ; whether there is a 
general inflammatory diathesis, or an enfeebled con- 
dition. These are the prominent points in an exami- 
nation of this kind. 

Where this predisposition exists, it may be coun- 
teracted by general or local treatment, according as 
it depends on general or local causes ; but in every 
case, this treatment should be very careful, and it 
will, in some instances, have to be protracted. In 
these cases, where there is a discharge through the 
fang of the tooth, such treatment should be adopted, 
as will most speedily and effectually suppress it ; and 
if it proceeds from a remaining portion of the nerve 
near the point of the fang, this should be removed. 



EXPOSED PULPS. 249 

and such application made as will prevent a recur- 
rence of the discharge, and assist the part to re- 
cover its health. The discharging surface may be 
broken up by cutting it away with an instrument, 
or be destroyed with an escharotic — either nitrate 
of silver, creosote, or chlorid of zinc, in the use of 
which, several applications will, in many cases, be 
necessary. From their action, the secreting surface 
is destroyed, healthy granulations spring up, and a 
normal condition is established. 

The discharge should be wholly suppressed before 
the tooth is filled ; otherwise, alveolar abscess would 
be speedily formed. In cases where there is peri- 
ostitis, it must be subdued before the tooth will tole- 
rate the operation of filling. To attain this end, 
the treatment to be adopted will be dictated by the 
nature of the causes which operate to induce the 
disease. General treatment will be indicated only 
when there is a constitutional condition favorable 
to the local affection ; but where there is no such 
general predisposition, the treatment should be wholly 
local, and may consist of the following or similar 
appliances : depletion, either by leeching, cupping, 
or scarifying the gums ; or counterirritation, either 
by scarifying, or by the application of highly stimu- 
lating lotions. Counterirritation may be produced, 
also, by making a deep incision in the gum oppo- 
site the tooth affected, and introducing a little flock 



250 EXPOSED PULPS. 

of floss or cotton, saturated with creosote, which 
is to' be kept in place till the inflammation of the 
periosteum is allayed ; which will be effected in from 
one to five days. The silk or cotton should be 
changed every day, till the restoration of the tooth 
to health is affected, when it is to be removed, and 
the wound permitted to heal. Mild stimulating 
applications to the gums in the immediate vicinity, 
so as to increase the circulation, will, in some cases, 
be all that is required. A vapor bath; or warm 
water applied to the part, is often beneficial; and, in 
some cases, a continued application of cold, by means 
of ice-water, will subdue inflammation of the perios- 
teum. Indeed, any antiphlogistic treatment that can 
be adopted advantageously, may be employed in 
periostitis. 

The periostitis of teeth whose nerves are dead, com- 
monly has its origin at the point of the fang, from irri- 
tation induced in the outstart by the dead and decom- 
posing pulp and other matter at that point. In many 
instances, the inflammation is not confined to the 
fang of the tooth on which it began ; but it will 
extend to the alveolus, the gums, and the periosteum 
of the neighboring teeth. Whenever the existence 
of this disease is suspected, and yet not very appa- 
rent, as is often the case, the examination should be 
very thorough. In some instances, a striking of the 
tooth at one particular point and at a certain angle. 



EXPOSED PULPS. 251 

will produce pain ; whereas, percussion on any other 
part of the tooth, or at any other angle, will cause 
none at all. By an exercise of care and discrimina- 
tion, the exact point of disease, if confined to a small 
space, may he ascertained. For instance, if striking 
on the labial surface of a central incisor near the 
point, produces pain in the socket, while striking on 
any other point would not, the place of the inflam- 
mation is the anterior portion of the fang, at or near 
its point. By such means, the skilful and discern- 
ing will be enabled to form a tolerably accurate 
opinion as to the extent and location of periostitis 
in all cases ; and this is an important consideration ; 
for, if inflammation is found confined to a small por- 
tion of a fang, the treatment, if local, should be as 
near that point as possible. 

Inflammation of the periosteum may sometimes be 
induced by the presence of foreign substances forced 
down between the free margin of the gum and the 
neck of the tooth, which have remained there till 
they have become vitiated, so as injuriously to affect 
the gums and periosteum. A deposit of salivary cal- 
culus sometimes produces inflammation of the gums 
and periosteum. Teeth otherwise healthy are, in 
some instances, thus affected ; though those which 
have lost their internal vitality, are much more liable 
to such disease. 

Preparing the Teeth for Filling. — After the tooth 






252 EXPOSED PULPS. 

has been brought to a healthy condition, the decayed 
cavity is first to be excavated and made of proper 
form, the pulp-chamber to be shaped, and then the 
canals and the fangs to be prepared for filling. For 
the preparation of decayed cavities here, the directions 
given on that subject hitherto, will be quite sufficient. 
In the formation of the pulp-chamber, the abrupt 
projecting portions of dentine should be cut down ; 
and if there is any decomposition of this, it should 
be removed. The pulp-chamber may be, when it is 
excavated, of a general retaining form, or there may 
be retaining points made within it at proper situa- 
tions. In the preparation of the canals in the fangs, 
some operators do nothing more than cleanse them 
out thoroughly. An other method is, to pass fine 
bur-drills into them as far as practicable, thus making 
the opening, of the same size all the way; or to scrape 
out the canal with a fine No.-lO excavator. Very 
fine, delicate instruments are required for cleansing 
out and forming the canals ; and they should be quite 
elastic and of low temper. Instruments for this pur- 
pose, are sometimes made of gold wire, to obviate 
the liability to break off in the tooth. But the best 
method of forming these canals, is with a three- or 
four-sided broach, tapering to a sharp point, and its 
inclination corresponding, as far as possible, with 
that of the fang. This instrument is employed to 
enlarge the canal, and give it a regular shape ; and 
a variety should be at hand, so that one of the proper 



EXPOSED PULPS. 253 

size and taper can be selected. In cleansing and 
forming the canal, care is necessary to prevent the 
instrument from passing entirely through the point 
of the fang. Such an accident is not very liable to 
occur with the tapered broach ; but with the minia- 
ture excavator or barbed wire, it is, — especially in 
the teeth of the young, where the foramina through 
the fangs are large ; and it is peculiarly apt to happen 
to the incisors, the canines, and the palatine roots of 
the superior molars. But, after the complete develop- 
ment of the teeth, there is no excuse for an accident 
of this kind ; for then there is an abrupt contraction 
of the canal near the point of the fang, which may 
always be detected by a careful introduction of the 
instrument. 

The decayed and pulp cavities and the canal all 
being thus prepared, are now ready to receive the 
filling. For filling the fang, there are several 
methods ; one of which is, to prepare small strips of 
gold, of two or four thicknesses of foil, take these on 
the point of an instrument, and pack them into the 
fang, in successive folds, till the canal is full. 
An other method is, to take small portions of gold, and 
pack them in, one on an other, till the fang is full. 
An other is, to take strips of from two to four thick- 
nesses, and from one to two lines wide, and roll them 
on a fine broach in such a manner as to make a cone- 
shaped block, a little longer than the depth of the 
canal to be filled, and of the same taper ; quite a 



254 EXPOSED PULPS. 

number of these blocks will be required for any given 
case', of various sizes, lengths, and densities ; the 
longest, largest, and least dense should be first used, 
the last requiring to be of less size and greater density. 
These cones may be made as dense as desirable by 
rolling them firmly between the thumb and fingers, 
after having taken them off the broach. They are 
taken up and introduced with the plugging pliers, 
and passed up as near to the point of the fang as 
consistent with safety. In some instances, there is 
danger of thrusting them through the point ; and, 
in order to prevent this, the end of the first block 
introduced may be made so large that it will not 
pass through, even when forced up ; or, what is 
probably better, a very small round pellet of gold 
may be forced up the canal, as near to the point of 
the fang as admissible, so as to serve to set the ends 
of the blocks upon, and prevent them from passing 
too far up. The cone-shaped blocks may be intro- 
duced and consolidated with an instrument of the 
same general form as the canal, but much smaller. 
This kind of instrument should be made of un- 
tempered steel ; though some operators make them 
of whalebone, to prevent breaking off in the fang, — 
an unnecessary precaution, since no skillful operator 
would ever break off a low-tempered, well-polished, 
properly-formed instrument of this kind. After a 
block is placed in the cavity, this instrument is 



EXPOSED PULPS. 255 

thrust in by its side, thus consolidating the gold to 
the side of the cavity. Thus, the blocks are success- 
ively introduced and consolidated, till the canal is 
filled. It is better so to arrange as to introduce the 
last portion of gold near the center of the canal, 
rather than at a side. The last blocks introduced 
should be stiff and dense, that they may be thrust in 
with considerable force. 

Another method of preparing the gold for filling 
fangs is, to take the pure metal, and roll it down, on a 
good rollingmill, as thin as possible, keeping it well 
annealed ; and of this, form the cones, and introduce 
them as already directed. Made in this way, they 
are stiffer, and fill up much more rapidly, than when 
made of foil. They are to be condensed in the same 
manner. Where the canal has been formed with a 
tapered broach, it may be filled with a gold wire, 
made of the same size and taper of the broach ; and 
this wire may be cut off at the orifice of the canal, or 
left protruding more or less into the decayed cavity, 
and be covered up with the filling. 

Some other substances have been thought quite as 
suitable for filling the fangs of teeth, as gold. Lead 
has been emploj^ed for this purpose ; but the prin- 
cipal difficulty with this is, to get it into such a con- 
dition as to be used with facility ; but, if as com- 
pletely introduced, it would probably answer the 
purpose quite as well as gold. Tin foil is also used 






256 EXPOSED PULPS. 

for this purpose, and, under favorable circumstances, 
with' success. Some experiments, too, have been 
made with plaster of Paris and similar substances, 
for filling fangs and pulp cavities; but with what 
success, it is not ascertained — some claiming instances 
of success, and others reporting, in every instance, 
failure; so that there are not sufficient data to war- 
rant the adoption of any of these substances into 
practice. 

In cases in which there is liability to irritation, 
the operation of filling a fang is quite enough for one 
sitting ; and in any case, not more than three fangs 
should be filled at one sitting. The filling of a large 
pulp-cavity will occupy one sitting, and that of the 
decayed cavity, an other. When a respite is thus 
had between the filling of the pulp cavity, and that 
of the decayed cavity, the former should be dressed 
down perfectly solid and smooth, so that no moisture 
may penetrate it ; and then, when the latter is to be 
introduced, the surface of the former should be rough- 
ened by being cut up with a sharp instrument, or by 
being indented with small retaining pits, so as to lay 
hold of and fasten the last filling. From one to four 
days should intervene between the different divisions 
of the operation. The filling of the decayed cavity 
is to be performed according to the directions already 
given. When inflammation ensues on an operation 
of this kind, recourse is had to the treatment already 



EXPOSED PULPS. 257 

described for preventing, counteracting, or reducing 
inflammation. 

Some experiments have been made to test the 
effect of restoring the parts to health, forming a cica- 
trice at the point of the fang, cleansing this out, fill- 
ing the pulp cavity and the cavity of decay, and 
leaving the canal unfilled ; and it is maintained that 
this method will, in favorable cases, answer the pur- 
pose quite as well as that of filling the fang, and 
incur less risk. The treatment will be such as 
already described for the restoration of diseased 
fangs; all discharge through the fang must be sup- 
pressed, and all foreign substances liable to decom- 
position, removed from the canal, so that there may 
be a complete restoration before this is closed. 

In case a discharge of pus is made into the canal 
after a tooth has been thus treated and filled; in case 
a decayed cavity has been filled before the complete 
suppression of the discharge; or in case a tooth is 
filled, and the pulp afterward dies : in either of these 
cases, it is necessary to make a vent for the escape of 
the pus. This is done by passing a small drill into 
the pulp chamber or canal, just above the filling, as 
close as possible. The handle of the drill should be 
depressed, so as to give the opening a downward 
inclination from within outward, and thus favor the 
escape of any secretion. 

In the superior molars, this opening may be made 






258 EXPOSED PULPS. 

through the fang. It is to be made through the 
masticatory surface ; it may, sometimes, be in the 
depressions on the crown surface, even though there 
be no filling. In incisors, it is made through the 
palatine portion of the crown. It is better, however, 
in all cases, to make an opening of this kind through 
the neck of the tooth, just under the free margin of 
the gum, since here foreign substances are not so 
liable to be crowded into it, as where it is through 
the masticatory surface. In cases in which it is 
obvious at the time of filling the tooth, that such an 
opening will be required, it is better to make it before 
the filling is introduced, as follows : first, prepare 
the decayed and pulp cavities for filling ; then drill 
through the neck of the tooth, into the canal, to the 
extreme part of the pulp chamber ; and finally, intro- 
duce into this hole, its entire depth, a piece of smooth 
steel wire, such as will closely fit, leaving it exposed 
through the decayed cavity — and if it is not enough 
exposed when introduced, the tooth-bone may be cut 
away about it, till it is fully exposed ; when the 
decayed and pulp cavities are filled in the usual 
manner, and condensed solidly against the wire. 
After the filling is finished, the wire is withdrawn, 
leaving a smooth, continuous opening for the escape 
of any secretion that may collect within. When the 
opening into the canal is not made till after the tooth 
is filled, there is liable to be a space between it and 



ALVEOLAR ABSCESS. 259 

the filling, that will fill up with fetid matter, and 
become very offensive. 

ALVEOLAR ABSCESS. 

Alveolar abscess is produced, in the first place, 
by the formation of a secreting sac at or near the 
point of the fang ; or, in the molar teeth, frequently 
in the bifurcation. The secretions of these sacs are 
different in character, according to the different con- 
ditions of the parts about. Sometimes, the discharge 
from these sacs is from the fang ; sometimes from 
between the tooth and the alveolus ; and sometimes, 
directly through the alveolus and gums. There are 
occasional cases in which the discharge will be at 
a very considerable distance from the point of secre- 
tion ; but, in such cases, the secretion always fol- 
lows some natural avenue that affords a facility for 
its passage — as, for instance, along a suture. There 
are two or three cases recorded where the issue from 
an abscess of the central incisor was near the poste- 
rior portion of the hard palate ; and, in these, the 
channel of the pus lay along the suture of the palate 
bones. Sometimes, the opening from an abscess of 
the first or second molars will be opposite the bicus- 
pids on the buccal portion of the gum. Alveolar ab- 
scess is exceedingly variable in character, according 
to the constitutional peculiarities and susceptibilities 
of the patient, the condition of the parts immediately 






260 EXPOSED PULPS. 

adjacent, and, to some extent, the cause which has 
produced it. In a good constitution, after an abscess 
is formed, it will discharge healthy pus. Occasion- 
ally, yet very seldom, does nature alone effect a per- 
manent cure. In constitutions of a cachectic dia- 
thesis, alveolar abscess is liable to constant discharge 
of an unhealthy pus, or purulent acrid matter ; and 
the parts about it are usually in a diseased condition. 

The cases in which alveolar abscess is most likely 
to occur are those of a manifest inflammatory diath- 
esis, or those in which there is considerable local 
inflammation, from some local exciting cause. In 
the cases of constitutional predisposition, the abscess 
assumes a chronic character, constantly secreting and 
discharging pus, but does not usually cause much 
pain, though the tooth from which it proceeds will 
experience some soreness and an uneasy sensation. In 
the acute forms of it, however, there will be intense 
pain. In some cases, the sac will be found producing 
its specific effects without much irritation of the sur- 
rounding parts ; while in others, there will be main- 
tained in them a high state of irritation, which is 
liable, also, to extend to parts more remote, especially 
if there are any irritating agents at work. Very 
seldom, if ever, are the parts involved in an abscess, 
restored by unaided nature to perfect health. 

The common cause of abscess is the presence of 
irritating matter in the canal at the point of the fang, 



ALVEOLAR ABSCESS. 261 

which, no doubt, in many cases, extends through the 
foramen at that point, inducing inflammation, and 
resulting in abscess. Usually, the sac is found at 
the point of the fang ; but, sometimes, it is located 
on the side, the point remaining comparatively free. 
In the molars, particularly the superior ones, the sac 
will frequently be found in the bifurcation, often 
occupying the entire space between the fangs. When 
it is on the point of one of the fangs, this is usually 

Fie. 34. 




the palatine. Fig. 34 represents the position of the 
sacs on the roots of the different teeth. 

Treatment. The treatment of alveolar abscess will 
be governed by the constitution of the patient and 
the condition of the part affected ; a case of recent 
origin will yield much more readily than one of long 
standing. When a case has assumed the chronic 
form, and the surrounding parts have become impli- 
cated in the diseased condition, a restoration to 
health is often very difficult. Indeed, till within a 
few years, the removal of alveolar abscess was 



262 EXPOSED PULPS. 

thought to be, as a general thing, wholly imprac- 
ticable. But, by the treatment now employed, this 
affection is readily cured, unless the parts in the 
immediate vicinity are very much involved. In 
some cases, the sac on the point of the fang is very 
large, and absorption has taken place, to accommo- 
date it; and, though in many such instances, the sac 
might be destroyed, yet the space occupied by it 
would not be filled up with a healthy deposition. 
In young persons, when an abscess is formed on the 
point of a fang, especially in the single-fang teeth of 
the superior maxillar, the discharge is frequently 
through the tooth, in consequence of the large size of 
the foramen of the point of the fang ; and generally, 
in such cases, the local treatment may be made 
through the canal. Sometimes the discharge is be- 
tween the fang and the wall of the alveolus. More 
often, however, especially in persons over twentyfive 
years of age, the discharge is through the alveolus and 
the soft parts to the surface, by the shortest course. 

When an alveolar abscess is influenced by cachexy 
or any other constitutional derangement, general 
treatment must be resorted to, such as the condition 
indicates. The local treatment always demanded, is 
such as will break up and destroy the secreting sac. 
This is effected either by surgical or by therapeutic 
treatment, and frequently in chronic cases, by both 
together; but, in the great majority of acute cases. 



ALVEOLAR ABSCESS. 263 

therapeutic treatment alone will be sufficient. In 
order to break up an abscess by an operation, it must 
be easy of access; and it is very seldom that an 
operation of this kind can be performed through the 
fang of a tooth ; but, fortunately, in almost all those 
cases where the discharge is through the fang, thera- 
peutic treatment alone will answer the purpose. 
When the point of discharge is on the gum opposite 
the secreting sac, a sharp-pointed bistoury should be 
used, and the canal of discharge sufficiently opened 
to admit the free use of the instrument at the seat 
of the disease. Then the secreting sac should be 
dissected from the point of the fang, and its connec- 
tion with the circulation severed as completely as 
possible, thus cutting off its supply. After this, if 
the case is a favorable one, nature may be left to 
accomplish the work ; in which case, the broken-up 
sac will be thrown off, healthy granulations will be de- 
veloped, and the parts be restored to complete health. 
In other cases, however, after an operation, nature 
unaided will not complete the cure ; but such thera- 
peutic treatment must be resorted to, as the circum- 
stances seem to require. In some cases, the opening 
through the alveolus will need to be enlarged ; and 
this part of the operation demands great care. All 
particles of bone should be removed from this open- 
ing, since, if permitted to remain, they would pro- 
duce irritation and tend to increase the difficulty. 



264 EXPOSED PULPS. 

When the therapeutic treatment is applied through 
the ' fang, the canal is to be cleansed of all 
foreign and detached matter, and opened freely 
through to the point ; and, if the discharge is very 
fetid, some disinfectant should be used, as chlorid of 
sodium or of zinc, since a fetid condition keeps up 
irritation. The cleansing of the fang may be accom- 
plished by injection of chlorid of sodium; after which, 
the agent to act on the disease at its seat, is to be 
introduced. Of this agent, there are various kinds 
employed, the chief of which are chlorid of zinc, 
nitrate of silver, and creosote, the first being applied 
in the solid, and the latter two in the liquid state — 
though the nitrate may be employed in the form of 
crystal. The method of using the chlorid is, to pass 
it in small portions up the canal, on a piece of silk, 
with a fine probe, entirely through the point of the 
fang ; which process should be repeated from two to 
six times, in as many days. After this, during two 
or three days, floss silk, moistened with a mild solu- 
tion of creosote and tannin in alcohol, should be 
applied daily ; and then clean silk or cotton may be 
worn in the canal, changed every day, for three or 
four days, or till it is manifest that there is no longer 
any discharge, and that the parts are in a healthy 
condition. If nitrate of silver, in solution, or creosote 
is used, it should be absorbed into a piece of floss silk, 
and passed through the fang in the manner already 



ALVEOLAR ABSCESS. 265 

described. The nitrate is more prompt of action 
than creosote, and will accomplish a specific object in 
a shorter time. Either of these solutions may, by 
the use of a syringe, be very effectively thrown 
through a fang in the following manner : fill the 
opening into the fang with gutta percha ; drill 
through it a hole large enough to receive tightly the 
point of the syringe ; and then, charging with the 
solution, inject it through the fang ; and, in cases 
where there is an opening through the gum, the 
injection may be forced round through this. The 
condition of the parts will indicate how long this 
kind of treatment should continue. Ordinarily, 
when the discharge is entirely through the gum, 
the bistoury should be used to enlarge the opening. 
In many cases, therapeutic treatment alone will 
accomplish the object ; and, when the opening to the 
sac is large and direct, the therapeutic agents may be 
introduced through it right to the seat of disease. If 
nitrate of silver, in solution, or creosote is used, it 
should be introduced to the point of affection on a 
pledget of cotton or floss, as heretofore directed ; or 
if, as is preferable, chlorid of zinc or nitrate of silver 
in solid, it should be passed through the opening into 
contact with the sac. This treatment should be kept 
up till the indications are fulfilled. 

In the treatment of abscess of the inferior maxilla 
much difficulty is often experienced from a want of 



266 EXPOSED PULPS. 

free egress for the secretion : while, in the superior 
teeth', the pus may frequently escape through the 
tooth by gravitation, this force, in the inferior jaw, 
increases the difficulty. The sac being usually 
formed on the point of a fang, the secretion then rests 
at the bottom of the socket, and is frequently pent 
up there till it finds an outlet through the gum, 
somewhere between the point of the fang and the 
neck of the tooth. It is, in many instances, very 
difficult to get an opening as low down as the point 
of the fang, since the buccal attachment to the gum 
is usually quite above the point of the fang, particu- 
larly in the case of the molars and second bicuspids. 
Very seldom, if ever, can a secreting sac on the fang 
of an inferior tooth be destro} T ed by treatment applied 
through the canal of the root. Some are accustomed 
to make a vertical incision of the gum, as low as the 
point of the fang, and perforate the alveolus, and 
treat through this channel, as already described. 
Owing to the disadvantage abovementioned, much 
more energetic treatment is necessary to attain suc- 
cess with the abscess of the inferior than with that of 
the superior teeth. 

In the great majority of cases, where one third or 
more of the periosteum of a root is involved in 
abscess, the indications certainly point to the re- 
moval of the tooth. In the lower teeth, a very 
serious difficulty occasionally occurs from abscess, 



ALVEOLAR ABSCESS. 267 

namely, an external opening and discharge ; and in all 
cases where this condition has already been reached, 
the offending tooth should be removed. But, when 
such a result is only anticipated, and is yet contin- 
gent, treatment may be employed to avert it ; and, 
in order to this, a deep and free incision should be 
made in the gum, opposite the affected tooth, and 
poultices applied within ; and, where there is ex- 
ternal swelling, pressure is recommended, as follows : 
adjust a piece of thick sheet-lead to the part, and 
make the pressure on this by means of a bandage 
comprising it and passing round the head. It is 
supposed that this application counteracts the gravi- 
tation of the secretion, pressing it upwards, and thus 
inducing it to seek an outlet at some more desirable 
point. If it is a worthless tooth that is producing a 
difficulty of this kind, it should be removed at once. 
In regard to the treatment of alveolar abscess, 
much yet remains to be learned. With the attain- 
ments thus far made in this direction, no aspiring 
dentist will rest satisfied. 



CHAPTER X. 

PIVOT TEETH. 

Whenever the crowns of anterior teeth have 
become so much decayed that they can not, by fill- 
ing, be rendered useful, they may, under favorable 
circumstances, be supplied by artificial crowns con- 
structed on the roots. For the successful accom- 
plishment of this work, the following conditions are 
important: 1. The constitution of the patient should 
be good. 2. The mouth should be in a healthy con- 
dition, and without diseased teeth or roots. 3. The 
teeth should be free from calcareous deposits and 
from all foreign substances liable to induce irritation 
or inflammation. 4. The attachment of the teeth 
should be perfect and health}', o. It is desirable 
that the root have a living, healthy nerve remaining. 
6. The root above the neck should be sound. 7. 
The root should occupy a correct position in the 
arch. Prior constitutional treatment will often be 
required where there are unfavorable conditions. 

The fangs of the six superior anterior teeth are 
better adapted for the reception of these crowns, than 






PIVOT TEETH. 269 

those of any other in the mouth. The fangs of the 
first bicuspids frequently terminate in two points, and 
are always more or less compressed, so that they will 
not receive a pivot large enough to sustain a crown ; 
besides, these teeth are masticatory, and crowns 
pivoted to them very soon become loose and useless. 
The roots of the inferior incisors are also compressed, 
and thus subject to the same disability. Occasion- 
ally, however, pivot crowns are attached to the roots 
of the superior bicusj3ids, and the inferior incisors, 
cuspids, and bicuspids. But in order that such an 
operation shall be of any utility, the conditions must 
be favorable, the roots with as little lateral compres- 
sion as possible, in a very sound and healthy state, 
and without any tendency to inflammation. 

The preparation of the root for the reception of an 
artificial crown, is a very simple process. It will, 
however, be somewhat modified by the kind of 
crown used, and the method of attaching it. Ordi- 
narily, the first step is, to remove the crown, or any 
remaining portion of it, with a fine saw or excising 
forceps. Of this latter instrument, there are various 
forms, that in most common use having narrow, 
transverse edges, closing squarely together, as repre- 
sented in Fig. 35. With these forceps, any broken 
fragments of the crown can be removed with great 
facility. Many operators, placing their edge on the 
neck of the tooth, are accustomed to excise with 






270 



PIVOT TEETH. 



them the principal part of the crown at a single cut. 
This ' method, however, is objectionable, since it 




always gives too great ajar to the root, and is liable 
to loosen, and, in many instances, to fracture it, so as 
to unfit it for the reception of the crown. But, in 
every case in which an artificial crown is required, 
the natural crown is very much decayed ; and, in this 
condition, is very readily removed with excising for- 
ceps, nipping it off in fragments, beginning where it 
is weakest and thinnest, and encroaching on it till it 
is all cut down — at least, as far as the forceps are 
available. Yet care is necessary even in this man- 
ner of using the forceps, lest the root be fractured or 
too much jarred. 

After such excision with the forceps, the root is to 
be dressed down for the reception of the crown, with 
a round, or, better, an elliptical file. But, for this 
operation of removing a crown, a very fine, smooth, 



PIVOT TEETH. 271 

narrow saw, set in a frame (Fig. 36), is, in some 
respects, preferable to the forceps, it being less liable 
to injure the root, than the latter. With this, the 



Ficr- 36. 




crown is sawed off at the margin of the gum, leaving 
the end of the root about the form required for the 
reception of the artificial crown. In the process, the 
crown being sustained by the fingers, the saw, kept 
constantly wet, is applied to the tooth, and passed 
along its proximal side to the margin of the gum, 
and then along this through it, cutting it off at right 
angles with its axis. After the crown has been thus 
sawed off, the root is fitted, with a fine, round file, 
for the artificial crown ; and, ordinarily, it should be 
dressed at right angles with its axis. 

At this stage of the work, if the nerve remains 
alive, it should be removed; and the preferable 
method is by direct operation, in the manner already 
described (p. 234). It is better, in all such cases, to 
avoid the use of arsenic for destruction of the nerve. 
It will often be necessary to destroy the pulp before 
the crown is removed. For a successful operation, it 
is always preferable that the root have the pulp 
living. After the pulp is removed, the canal is to 



272 PIVOT TEETH. 

be enlarged to a suitable size, with the appropriate 
drill. If there is any remaining sensitiveness of the 
dentine, as is very seldom the case, the bur drill may 
be used for this purpose ; but if not, then the com- 
mon spear-pointed drill will be best. . Where, how- 
ever, the canal takes the form of a mere fissure, 
either the bur drill or the four-sided broach may be 
employed. The depth to which the canal should be 
enlarged, will be determined by the length of the 
fang; but it should, in all cases, be sufficient firmly 
to retain a pivot — which is from one to two lines; 
and the diameter of the hole will be modified by the 
size of the root. The drills should be frequently 
moistened with water, to prevent their clogging. 
The shaft of the instrument, in the operation, should 
be in a line with the cutting edges of the two adjoin- 
ing teeth, and midway between them; and the drill 
itself should follow the natural canal as nearly as 
possible. 

FITTING THE CROWX. 

The tooth selected should be of a size, shape, and 
color to correspond with the natural crown which it 
is to represent. It should not be ground on the 
sides or points; indeed, ought not to be touched with 
the emeryw T heel at all. The diameter of the neck 
of the crown should correspond with that of the 
articulating surface of the root to which it is to be 



FITTING THE CROWN. 273 

attached. In fitting the crown to the root, the point 
should be made as nearly perfect as possible ; for the 
tooth is thus more permanent and comfortable; an 
open point offers a receptacle for the lodgment of 
food and other foreign substances, where they 
become vitiated, and produce unpleasant, if not inju- 
rious effects. The crown may be principally fitted 
to the root without pivot, by dressing it with a round 
or elliptical file, and frequently trying it on in about 
its proper position. After having been thus pretty 
accurately fitted, a trying pivot of soft wood should 
be introduced, by means of which, grinding it to its 
exact position, the crown may be fitted to the root. 

For fitting on pivot teeth, Dr. E. Townsend in- 
vented a kind of round or convex file, with a con- 
cave counterpart, into which the file exactly fits ; 
with the former of which the root is dressed, and 
with the latter, the articulating surface of the crown. 
This apparatus would be very good, were it not for 
the great difficulty of dressing porcelain teeth. By 
care, a very complete fit can be made with a round 
file alone. Some coloring material, as rose pink, for 
instance, may be put on the base of the crown, and 
then the tooth, with the pivot inserted, set in its 
place — when the root will be marked where the 
crown has touched it, and can be dressed at the 
point of contact. This operation is repeated till a 
perfect fit is attained. This method is to be recom- 



274 PIVOT TEETH. 

mended to those who have had but little experience 
in fitting pivot teeth. 

An other method of making the articulation is, to 
dress the end of the root square, and then counter- 
sink it about half a line deep with a square-ended 
bur, about three fourths the diameter of the root. 
The base of tke crown is then ground down, by the 
measure of the bur, perfectly round, so as exactly to 
fit into the depression in the root. The bur used for 
countersinking the root should have a center-point to 
fit into the hole in the fang, and thus guide the instru- 
ment. This method of fitting on crowns is objection- 
able, by reason of its too great exposure of the root 
of the tooth. Fig. 37 represents the bur used for 

Fig. 37. 



this purpose. It is a method now very seldom em- 
ployed. 

Still an other method of making an articulation is. 
to dress up the root as first described ; then take an 
impression of the part in plaster of Paris ; and from 
this, get a model, to which to fit the crown. This 
method, however, is advisable only in cases where it 
is desirable to avoid annoyance to the patient by a 
tedious fitting process. 



ATTACHMENT OF THE CROWN. 275 



ATTACHMENT OF THE CROWN. 



The means of attachment in most common use is 
that of wood pivots ; for which, wood in the natural 
condition is ordinarily employed, though it is much 
improved by compression. The kind best adapted 
for pivots is the fine-grain, tough, slow-growth hick- 
ory, of straight, uniform fiber, which should be 
thoroughly seasoned. For its preparation, take 
blocks, six or eight inches long, and split them into 
rods, about one fourth of an inch square ; then, with 
a knife and file, dress them down to a size one third 
greater than that of the intended pivots ; afterward, 
pass them through three or four holes of the ordinary 
drawplate inverted, thus making them of uniform 
thickness throughout ; and finally, turning the draw- 
plate, pass them through it in the same manner as 
wire, continuing till the rods are of proper size, and 
all the pores of the wood are closed by compression. 
They should be slightly oiled before being drawn 
through the plate. They may be drawn so as just 
to fit the holes of the artificial crowns, being, of 
course, of different sizes. Pivots thus compressed are 
stiffer, stronger, and far more durable; and, there 
being greater density of fiber, there are less absorp- 
tion of moisture, less expansion, and less liability to 
decay, than in wood in the natural condition. 

In arranging the crown in position, care is necess- 






276 PIVOT TEETH. 

ary to prevent it from being struck by the teeth of 
the Opposing jaw, — especially since it often happens, 
where the natural crown has been gone for some time, 
that the corresponding tooth of the lower jaw becomes 
somewhat elongated, and strikes forcibly against a 
properly-adjusted pivot tooth. Such ah accident is 
anticipated either by filing off the elongated tooth, or 
by grinding out the palatal portion of the artificial 
crown sufficiently' to accommodate the elongation. 
The former is the better method, and should always 
be adopted when inflammation of the dentine, exposure 
of the pulp, or an irascible condition of the surrounding 
parts, does not forbid it : though, in many instances, 
both methods may be advantageously employed. 
But, by whatever means, the antagonizing teeth 
should always be prevented from coming in contact 
with the artificial crown ; and this latter should 
never press against the tooth, on either side of it ; — 
indeed, it would be more desirable that there should 
be a small interval on each side. 

When the crown is in its proper position, the hole 
in the root and that in the crown do not always have 
precisely the same direction ; in which case, a pivot 
will be required, having a curvature according to the 
variation ; and the extent and direction of such in- 
flection, should be carefully observed while adjusting 
the crown with the trying pivot. The pivot is to be 
neatly and accurately fitted into the crown first, and 



ATTACHMENT OF THE CROWN. 277 

then the length of it required for the root, ascertained 
with the gauge represented in Fig. 38. This gauge 

Fig. 38. 




consists of a wire of a size freely to enter the pivot-hole, 
having a little slide with a flange attached. By in- 
troducing this wire into the pivot-hole, the slide is 
pressed back, and the depth of the hole indicated at 
once. The pivot is then cut off accordingly, and 
dressed to the proper size and inclination, and gently 
pressed to its place with the thumb and fingers. 
Before being introduced, however, it may be wrapped 
with gold foil, which will serve to protect the dentine 
of the root from decay, and also to preserve the pivot. 
Two or three thicknesses of gold foil, too, may be 
placed between the crown and the root, so as to make 
a more perfect joint and exclude the moisture. There 
is, however, not much advantage in an arrangement 
of this kind ; a thin sheet of Hill's Stopping placed 
in the joint, makes a better adaptation than the gold, 
and collodion or a solution of chloroform and gutta 
percha may be used for the same purpose. The 
canal in the root above the pivot should be filled with 
gold ; though, in cases where there is a discharge 
through the fang, this would not be admissible. 



278 PIVOT TEETH. 

The canal at the orifice is sometimes considerably 
enlarged by decay, so that when the crown is fitted, 
and the canal sufficiently opened for the reception of 
the pivot, there will be a cone-shaped space which 
the ordinary pivot will not fill. There are several 
methods of obviating this difficulty ; one of which is, 
completely to fill the enlargement with gold, and then 
perforate this filling with the proper-sized drill for the 
reception of the pivot ; or, which would be better, to 
introduce into the canal a polished steel wire of the 
size of the intended pivot; round this consolidate a 
filling of gold, having first made retaining points at 
the proper places in the dentine ; finish perfectly 
flush with the end of the root; and then withdraw 
the wire from the canal, and it is ready to receive the 
pivot with the crown attached. Some operators form 
the wood pivot of such a shape as to fit into and fill 
the enlarged cavity. An other method is, after the 
pivot is fastened into the crown, to build round it, on 
the base of this, a portion of Hill's Stopping, of about 
the size and form of the enlargement in the canal ; 
and then, the tooth being ready to insert, to soften 
the stopping by heat, and introduce carefully into 
place. This, when skillfully performed, is probably 
as good a method as any other. 

It frequently happens, in cases where the nerve 
has been dead for a considerable time, that there is 
more or less discharge through the canal of the fang. 



METALLIC PIVOTS. 279 

and a tooth is required immediately, or at least 
before there is time for treatment to abate the dis- 
charge. To such a condition some arrangement 
must be adapted, so as not entirely to close up the 
canal, and preclude the escape of pus. For this pur- 
pose, a groove may be cut down the wall of the 
canal, or, perhaps, on the side of the pivot through- 
out its length, for the discharge of the secretion. 
Where there is irritation or liability to inflammation, 
a temporary pivot of soft wood, or of hard wood 
loosely fitted, should be worn ; for thus the root is 
less jarred by percussion on the crown, and, if need 
be, the crown and pivot can be removed. 

METALLIC PIVOTS. 

The liability of a pivot of wood to wear off at the 
point between the crown and the root, as well as to 
become offensive, and the difficulty of removing the 
tooth, have led dentists to seek some less objection- 
able material ; and metals have been experimented 
upon, and found in some respects preferable. Gold 
has been employed for this purpose more than any 
other metal. Pivots made of this do not become 
offensive, do not wear off, and admit of any desired 
curve, and of an easy removal of the crown. There 
are several methods of attaching this kind of pivot 
to a tooth ; and a very common one is, to fit into the 



280 PIVOT TEETH. 

hole in the crown a piece of pivot wood — cut it off 
even with the base of the crown, and perforate it 
with the -proper-sized drill for the reception of the 
metal pivot, which may be roughened, or barbed on 
some of its sides, and then forced into the place pre- 
pared for it. An other method is, to drill "into a 
block of wood ; insert the pivot, prepared as above, 
then dress down the wood round it till this will fit 
closely into the crown ; and, after it is pressed in, 
cut off the protruding portion of wood. In either 
of these methods, when the wood becomes moist, 
the metal pivot will be very firmly retained. 
This pivot may also be firmly attached to the 
crown by soldering : place the edge of the tooth in 
plaster of Paris ; set the pivot in its proper position 
in it; fill round this with fragments of gold plate, 
and put on solder and borax; heat up with a blow- 
pipe, and draw the solder to the bottom of the cavity. 
An other method, sufficient for all practical purp 
is, to set the pivot in place, and, packing round it a 
stiff amalgam of gold and mercury, evaporate the 
mercury by heat. A better method than any of 
these is, to have teeth manufactured with a plati- 
num tube inserted, into which the pivot can be 
soldered. Pivots may also be attached to the ordi- 
nary plate teeth. 

For attaching the metal pivot to the root, it is 
sometimes fitted tightly to the canal, and introduced 



METALLIC PIVOTS. 281 

into it without any other substance. This is objec- 
tionable, on account of the wearing of the root, certain 
to take place, if there is the least jarring or moving 
of the crown. To obviate this, various methods 
have been devised ; one of which is, to wind floss 
silk about the pivot before introducing it; but this 
soon becomes offensive, and requires very frequently 
to be renewed. An other method is, to introduce a 
piece of wood into the fang, and drill through it for 
the reception of the pivot, which is squared and 
roughened — squared to prevent it from turning 
round, and roughened to secure it from drawing out. 
But if it is desirable to remove the tooth occasion- 
ally, the pivot should not be barbed. 

Metal tubes may be introduced into the fangs for 
the reception of the pivots. These tubes are made of 
hollow gold wire of proper size ; the method of pre- 
paring which, is, to take a piece of No.-30 gold plate, 
from four to six inches long, and from a third to a 
half an inch wide, and bend it round a piece of smooth 
polished steel wire of the size of the intended pivot ; 
draw both together through a drawplate, down to one 
size larger than the hole in the fang ; then take out the 
wire, and solder up the tube ; on it cut a fine thread 
with a screwplate ; from it cut off from a half to three 
fourths of an inch in length, and insert into this a 
piece of the wire it was drawn upon ; grasping this 
section with a small vice or pair of nippers, screw it 



282 PIVOT TEETH. 

carefully into the root ; and, having introduced it 
far enough, withdraw the piece of wire, cut off the 
protruding piece of tube with a fine saw, and file and 
neatly polish. The root is thus ready for the recep- 
tion of the crown, the pivot of which should fit very 
accurately into the tube. A very slight inflection of 
the pivot will enable it to retain a very firm hold in 
the tube. The tube's inner end may be soldered up 
if desirable ; and, if there is decay at the orifice of 
the canal, a flange may be soldered on to its outer end, 
flush with the end of the root, and the decayed 
cavity filled beneath it, the flange serving to retain 
the filling perfectly in place. These tubes can be 
best fitted in with the screw, though they are some- 
times placed in without this, and foil packed about 
them to retain them. They may be made to receive 
a square pivot, by being drawn, in their manufacture, 
on a square wire, in stead of a round one. For the 
escape of pus, as already referred to, the pivot may 
be made of hollow wire, with a hole through the 
crown of the tooth. 

A plate tooth, with a metallic pivot attached, may 
be used in stead of the ordinary pivot tooth ; and it 
is in some cases required, on account of the manner 
in which the teeth antagonize. But in all cases 
where a plate tooth is used, it should have a metallic 
base to rest on, and cover the end of, the root. Pro- 
perly to construct this, an impression must be ob- 



METALLIC PIVOTS. 283 

tained, and models and countermodels made, and 
the base swaged ; and then to this the pivot and 
tooth are attached. Irregularity of the teeth, and 
especially of the root on which the crown is to rest, 
may require a peculiar adjustment of the pivot, which 
may be very happily effected by the method just re- 
ferred to. 

Occasionally, bad consequences follow the opera- 
tion of inserting a pivot tooth, the most frequent of 
which is, inflammation of the periosteum. Kough 
manipulation is very liable to induce this condition, 
where there is an inflammatory diathesis; in which 
case, too great care can not be recommended ; and 
prior treatment will sometimes be advantageous. 
After periostitis has supervened, either constitutional 
or local treatment, or both, may be employed ; con- 
stitutional, by emetics and saline cathartics, and, 
indeed, any agent that will equalize the circulation 
and counteract the inflammation ; and local, by the 
same means as already prescribed for periostitis else- 
where — in addition to which, it may sometimes be. 
necessary to remove the crown and pivot from the 
root. It is always important to commence the treat- 
ment of such cases at the first indications of the 
disease. 

Sometimes, even with considerable care, a crown 
will be split by the introduction or the expansion of 
the pivot; in which case, of course, an other tooth 



284 PIVOT TEETH. 

must be selected. When a pivot breaks off, and a 
portion adheres in the fang, this may be drawn out 
with pliers or a pivot-extractor, or, if it does not pro- 
trude enough for this, it may be drilled out. A fang 
is sometimes split by the expansion of a tightly-fitting 
pivot, or by a blow on the crown of the tooth ; and 
when this happens, it must be removed, since it can 
not be made any longer to retain a tooth. Pivot 
teeth should seldom, if ever, be worn in a mouth in 
which teeth on plate are worn. In any case, indeed, 
they are now far less frequently worn than they 
formerly were, because, perhaps, of the improved 
methods of inserting teeth on plate. Under favor- 
able circumstances, however, they may be worn with 
great comfort and usefulness, from five to fifteen 
years. 



CHAPTER XL 

EXTRACTION OF TEETH. 
GENERAL REMARKS. 

The extraction of teeth is an important operation, 
requiring, for its proper performance, skill, judgment, 
and experience, as well as an accurate knowledge of 
the parts to be acted upon. Success in the operation 
used to be very uncertain ; but now, from an increase 
of knowledge in the art of dental surgery, and from 
great improvements in the instruments employed, the 
operation is generally attended with success. The 
ancients were not strangers to this operation, as is 
evidenced by relics found in ancient tombs, with 
teeth absent, under such circumstances as to warrant 
the conclusion that they were removed by the sur- 
geon. Extracting instruments of very ancient date 
have also been found ; and ancient writers, too, refer 
to the operation as one not much more pleasant then 
than now. The demand for this operation rises not 
from fancy, fashion, or caprice, but from dire necess- 



286 EXTRACTION OF TEETH. 

ity — a necessity, too, of great frequency. Very few 
individuals in this country arrive at mature age with- 
out being required to submit to it ; and, indeed, the 
majority, before middle age, lose in this manner from 
four to ten teeth, and many, all. The following are 
some of the objects for which a resort is had to this 
operation : — 

1. To obtain relief from pain, caused either by 
disease of the pulp, by inflammation of the perios- 
teum, or by any other affection involving -the teeth, 
that can not be readily controlled without their 
removal. 

2. To prevent pain in future. This, of course, has 
reference only to those teeth which are very much 
decayed, or rendered useless by any cause, and which 
are liable at any time to occasion disease in the parts 
about them. 

3. To save sound teeth from the attack and ravage 
of decay. This implies those teeth which, by their 
offensive condition, would prove injurious to healthy 
teeth. 

4. To relieve a diseased condition of the contigu- 
ous parts, such as alveolar abscess, neuralgia excited 
by dental irritation, diseased antrum — and some- 
times, indeed, remote parts, which are in many 
instances affected by diseased teeth. 

5. To anticipate and obviate irregularity. Of this 
there are many cases, in which all the teeth can not 



GENERAL REMARKS. 287 

be accommodated with a proper position in the arch, 
and in which the removal of one or more of them, 
for this purpose, becomes a necessity. 

6. To prepare the mouth for a proper reception of 
artificial teeth on plates. Though plates are some- 
times inserted, with the roots of teeth remaining, yet 
a perfect operation can never be effected without 
their removal. 

Before anything else is done, every case presented 
should be carefully examined, in order to ascertain 
all the circumstances and conditions that might in 
any way affect the operation. It is important to 
arrive at a correct conclusion in regard to the tooth 
or teeth to be removed; the number of fangs, their 
inclination, and the character of their attachment; 
in what manner, and to what extent the surround- 
ing parts will be affected by their removal ; and the 
probable amount of force necessary for this purpose. 
The operator will, in many instances, be referred to 
the wrong tooth; for a sound and healthy tooth is 
sometimes painful from sympathy, and, standing in 
contact with a decayed and painful one, makes it 
many times difficult for the patient to determine in 
which the pain exists ; and sometimes difficult for the 
operator, too, especially where the decay is on a 
proximal portion of the. tooth, and not easy of 
approach. In all such cases, great care should be 
exercised, and a thorough examination made. There 



288 EXTBACTION OF TEETII. 

is often extensive decay on the proximal portion of 
the tooth, that is not apparent at first view. 

The constitution is also to be noted — its peculiar- 
ities, tendencies, and susceptibilities; as these will 
often modify the operation. A highly nervous tem- 
perament will not endure an operation that- one of 
a different character will undergo with impunity. 
There may also be idiosyncrasies and conditions that 
will forbid the extraction of a tooth. One of these, 
and not the least formidable, is a hemorrhagic dia- 
thesis. 

The manner of performing the operation is an 
important consideration : it should not be precipi- 
tate or hurried. A very good criterion is, that the 
eye should critically follow, and the mind attentively 
comprehend every movement of the hand and instru- 
ment. It is a very common method, to seize the 
tooth, turn away or shut the eye^. and make the 
most rapid motions possible, regardless of coi 
quences. Accidents, such as breaking of the tooth, 
fracturing of the alveolus, laceration of the soft parts. 
and rupture of the bloodvessels, are very liable to 
follow such a hurried execution ; and there are many 
cases on record, in which injury has resulted from a 
rapid application of force in the extraction of teeth. 
The ancients were cautious in this particular : it is 
recorded of them, that they made extracting instru- 
ments of lead, to prevent injury from the employ- 



GENERAL REMARKS. 289 

ment of too great force. It is difficult, indeed, 
always to determine what amount of force may be 
necessary for the removal of a tooth in any given 
case ; though by long and close observation, it may 
be pretty accurately calculated; and it is important 
for the operator to know it, so as to prepare for the 
emergency, and to select the instrument appropriate 
to the occasion. In order to be successful, an ope- 
rator must be confident of his ability, and, to be so, 
must be possessed of it. He should be familiar with 
the anatomical structure of the parts to be operated 
upon ; should understand the physiological and the 
pathological conditions of the parts adjacent; and 
should properly appreciate their influence on, and 
their connection with, the teeth. 

There is a great difference in teeth with regard to 
their facility of removal. Those most difficult to ex- 
tract, possess the following peculiarities : shortness 
and thickness of crown ; in the incisors, thickness — 
the edges of the superior and the inferior meeting 
squarely on, or deviating but little from their points ; 
freedom from prominences on the crowns of the mo- 
lars and bicuspids, their masticating surfaces being 
smooth ; regularity in arrangement, all being in cor- 
rect position and in contact with one an other ; color 
slightly yellow ; denseness and thickness of alveolus; 
unyielding firmness of the soft tissues ; lack of promi- 
nences on the gums to indicate the size and position 

T 






290 EXTRACTION OF TEETH. 

of the fangs. An other class of teeth, differing in 
characteristics from those of the above, are also very 
difficult of extraction, namely : those having crowns 
of medium length and of a diameter at the neck 
much less than at the masticating surface ; fangs long 
and divergent, and in some cases considerably 
curved ; sometimes an osseous attachment, and often 
a very firm union with the alveolus, even where 
there is no bony attachment, so that a portion re- 
mains adhering to the tooth when it is extracted ; 
which occurs more frequently with the superior cus- 
pid teeth than with any others; and often the septum 
between the fangs is so firmly embraced by them, 
especially when they converge, that it is brought 
away with the tooth on its extraction. Bony union 
of the teeth has been enumerated as one of the occa- 
sional obstacles in extraction of the teeth ; but this 
is of so very rare occurrence — the mode of develop- 
ment almost precluding the possibility of its exist- 
ence — that it need scarcely be reckoned. Exostosis 
of the fling sometimes renders extraction very diffi- 
cult, especially when the enlargement attaches to the 
point of the fang, and forms a bulb larger than the 
diameter of the root elsewhere. It is then like a 
ball in a socket, and, if the walls of the alveolus are 
thick and firm and closely embrace the fang, the 
tooth is very securely retained. Exostosis of the 
same extent in the inferior as in the superior teeth, 



GENERAL REMARKS. 291 

will render the latter the more difficult to remove, 



because of the greater density of the inferior max- 
illa ; and it has been maintained that this cause 
would produce a like difference even in the normal 
condition of the organs ; but experience does not 
warrant the opinion. The superior molars have 
more numerous and more divergent fangs than the 
inferior ; and the fangs of the anterior superior teeth 
are much larger, and consequently have a greater 
amount of attachment, than the anterior inferior 
ones. In a healthy condition, the periosteum of the 
fang has comparatively little sensibility ; but in pro- 
portion as it is subjected to acute disease, is the sensi- 
bility, and thus the pain consequent on the removal 
of the tooth, augmented. 

Instruments adapted to all the different forms and 
locations of the teeth, are requisite in the various 
operations of extraction. It is impossible to remove 
all teeth in a proper manner with but three or four 
instruments, as recommended by some. 

For any kind of successful manipulation in the 
mouth, and especially that involved in the extraction 
of teeth, the patient should be placed in such a posi- 
tion as to make him the most comfortable, and to 
secure to the operator the greatest facility of execu- 
tion. But different positions, of course, will be re- 
quired for the removal of different teeth. Finally, 
there should be as little show of preparation and as 



292 EXTRACTION OF TEETH. 

little display of instruments as possible — thus to 
avoid exciting the nervous apprehensions of the 
patient ; and the operator should at all times exhibit 
a gentle and encouraging deportment, jet work 
promptly and surely. 

INDICATIONS FOR EXTRACTION. 

The most common and imperative indication is, 
continued and violent toothache. In all cases where 
the teeth are diseased and painful, and can not be re- 
stored to health, they should be removed. There 
are, however, few cases of diseased teeth, that cannot 
be relieved by the present methods of treatment, so 
as to remain in the mouth with some degree of com- 
fort and usefulness. Alveolar abscess terminating on 
the outside of the nice, or tending to it, always indi- 
cates the removal of the offending tooth. Chronic 
inflammation of the investing membrane used to be 
considered an indication for extraction ; but it is 
found that many cases thus affected, may, by judi- 
cious treatment, be restored to comparative health. 
Ulceration of the investing membrane clearly points 
to extraction as the remedy. Teeth that have no 
antagonists, and that, on this account, keep up an ir- 
ritable condition in the contiguous parts, should be 
removed ; and so, as a general rule, should super- 
numerary teeth. In order to relieve a crowded con- 



INDICATIONS FOR EXTRACTION. 293 

dition of the teeth, it is sometimes necessary to re- 
move one or more, even though they may be healthy. 

Till within the last few years, the existence of an 
alveolar abscess was considered an indication for the 
removal of the tooth from which it proceeded ; but, 
under the present mode of treatment, except in very 
aggravated cases, a simple abscess is not reckoned a 
sufficient cause for extraction. 

The posterior teeth may be removed for causes 
that would not warrant a removal of the anterior. 
All dead teeth and roots that produce or keep up irri- 
tation, should be removed, especially if the tendency 
is persistent. 

The temporary teeth that are not cast at or near 
the time their respective permanent teeth should ap- 
pear through the gum, ought to be removed ; but 
caution must always be exercised, lest they be re- 
moved too soon. Painful and uncontrollable disease 
may indicate their removal long before the period just 
mentioned ; yet they should not be removed on ac- 
count of diseased condition, unless the rudiments of 
the permanent teeth are likely to suffer thereby. A 
crowded condition of the permanent with the tempo- 
rary teeth, may indicate the removal of one or more 
of the latter. It is important to understand the true 
indications for the removal of temporary teeth ; in 
these, as in the permanent teeth, apparent indications 
are liable to be mistaken for real ones. Teeth may 



294 EXTRACTION OF TEETH. 

sometimes, even though undecayed, produce nervous 
affections, and in such a manner as to render their 
removal necessary. This indication is most frequent 
with teeth affected by exostosis. 

A high state of inflammation in the contiguous 
parts, is regarded by some as a counter indication ; 
but it can be such only in cases in which the inflam- 
mation would be increased by the operation; and 
this would happen only where there is a decided 
inflammatory diathesis; which peculiarity can be 
readily detected by a little carefulness of observation. 



EXTRACTING INSTRUMENTS. 

Numerous and various instruments have been 
employed for extracting teeth ; and each of these 
has passed through various modifications. Imper- 
fection and inadaptation have, till within a few years, 
characterized them all in a marked degree, as indi- 
cated by the numerous changes they have undergone. 
Two general classes comprehend them all — repre- 
sented by the key and the forceps. The former 
makes its attachment on one side of the tooth, 
coming in contact with but a small portion of it, and 
has a resting point for a fulcrum on the adjacent 
parts, the gum and the alveolus. The latter em- 
braces the tooth on both sides, and has no fulcrum 
resting on the adjacent parts. There are other in- 



THE KEY. 295 

struments somewhat different from these in their 
application; but the principle on which they operate, 
is the same. For instance, the elevator has a point 
of embrace or contact with the teeth, and a fulcrum 
or resting point, on the adjacent parts, the power 
being applied to the handle, as to a lever. The 
screw makes its attachment inside of the tooth, 
instead of outside, like the forceps, and does not 
touch any otner part. 

There should always be at hand a sufficient 
number and variety of instruments to meet every 
case, however rare its occurrence. Desirabode re- 
commends the employment of but four instruments 
for the removal of all the teeth : the first is a forceps, 
and the other three are nothing more than so many 
different forms of the elevator. He was not familiar 
with the present improvements in extracting instru- 
ments, or he could not have made such a recom- 
mendation. 

THE KEY. 

The principle of this instrument was, at a very 
early period, brought into requisition for the extrac- 
tion of teeth; it is, emphatically, an old instrument. 
It consists of a shaft six inches long, with a handle 
four inches, attached at right angles, while the hook 
is attached laterally at the other end of the shaft, 
and the bolster, either movable or fixed, to the side 



296 EXTRACTION OF TEETH. 

of it, immediately below the articulation of the hook. 
This' instrument has passed through a great variety of 
forms and modifications; having the shaft straight, 
curved, double-curved ; the fulcrum large, small, flat, 
round, long, short, fixed, movable, and anterior, pos- 
terior, or opposite to the point of the hook. There 
has also been a great variety of forms of the hook; 
and it has been made with machinery attached, to 
control its grasp, the object of which it, to prevent 
the instrument from slipping off the tooth', and skill 
in the use of which would doubtless add to the effi- 
ciency of the instrument. The principle of the 
forceps, too, has been combined with the key, and 
probably with very decided advantage. 

The modus operandi of the key is worthy of some 
consideration. . The hook is attached to the shaft 
directly above the bolster, and starts off at right 
angles with its vertical axis, but curves down to the 
point, almost or quite as low as the base of the bolster. 
When properly constructed, the hook embraces the 
tooth at the neck on one side, and the bolster rests a 
little below this on the other. When the instrument 
is applied to a tooth, the center of the shaft is the 
axis of motion ; but, as force is applied to the instru- 
ment, this axis is transferred from the shaft to the 
base of the bolster, which is the center of motion the 
moment it is fixed on the gum and alveolus, and the 
shaft describes an arc about it. Now, as a result of 



THE KEY. 297 

this motion and arrangement, the line of force is at 
an angle of from forty to sixty degrees with the axis 
of the tooth ; and hence it is at this angle that the 
tooth must be extracted, if at all. The axis of power 
exerted on the tooth by the instrument, is in a line 
from the point of the hook to its attachment to the 
shaft ; and the line of this force has its termination 
below the neck of the tooth on one side, and just 
above the crown on the opposite side. The angle 
formed by the line of power with the axis of the 
tooth, is different in the different relative positions of 
the key to the tooth. If the instrument is applied to 
an inferior molar, with the bolster on the inside, the 
angle of the line of force with the axis of the tooth is 
about forty degrees ; but, if placed on the outside of 
the jaw, as recommended by some, the angle con- 
tained by the line of power and the axis of the tooth, 
is sixty degrees or more. The line of force is not 
changed by any form the hook may assume ; — it may 
be regularly or irregularly curved, or be turned at 
right angles, and yet the line of force not be changed 
at all. Indeed, this line can not be changed, except 
by changing the relative position of the hook and its 
attachment. This application of the power constitutes 
one of the prominent objections to the use of the in- 
strument : the force is applied at too great an angle 
with the axis of the tooth, and hence, in numerous in- 
stances, this is broken off. The bolster of the key rests, 



298 EXTRACTION OF TEETH. 

in the operation, on the gum, on which it exerts great 
pressure, and which it always bruises, and frequently 
lacerates in a cruel manner; and the degrees of press- 
ure exerted by the bolsters of the variously con- 
structed keys differ but little ; though, perhaps, the 
bolster which has a broad base, and which is attached 
to the shaft by a joint, would cause less pain to the 
patient by its pressure, and be much less liable to 
lacerate or cut the gum, than the small and perma- 
nent one. The pressure of the bolster on the gum 
and process is always greater than the power required 
to extract a tooth ; and this extreme pressure and its 
consequences constitute an other strong objection to 
the use of this instrument. The power being applied 
at a disadvantage, much more of it is required than 
when economically applied. 

This instrument is so seldom employed for the 
extraction of teeth, that any very special directions 
as to its use will scarcely be required ; yet a few lead- 
ing suggestions may not be out of place. Whether 
a tooth should be drawn inward or outward depends 
on its position and inclination. As a general rule for 
the removal of the molars, the bolster should be 
placed on the inside of the inferior teeth, and on the 
outside of the superior. For removing the lower teeth 
of the left side, the operator should stand at the right 
of the patient ; and for the teeth of the right side, in 
front or at the right. For the inferior teeth of the 



FORCEPS. 299 

right side, he should stand at the right of the patient; 
and for the left superior, in front of him. There have 
been a great many different opinions as to the manner 
of applying and using the instrument. One recom- 
mends that " the teeth should be always turned 
towards the tongue." An other, " that the fulcrum 
should be so placed that it would not come in contact 
with the tooth." An other directs : " Place the ful- 
crum on the margin of the gum." An other : " Place 
the fulcrum on the gum below its margin." An other 
suggests, " that the fulcrum be placed on the side of 
the tooth opposite the point of the hook." Again, 
we are directed "that the tooth should be drawn 
from the higher alveolus." This great diversity of 
opinion as to the manner of using the key, as well as 
the great variety of changes in its form, is evidence 
that it is, at best, a very imperfect instrument. It is 
impossible to embrace a tooth as deep with it as with 
well-constructed forceps ; and with it, the chances of 
accident in the extraction of teeth, are much greater 
than with any other instrument. A strong advocate 
of this instrument says that "the key ahvays produces 
injury; but the greatest skill exhibits the least 
injury." 

FORCEPS. 

The forceps are the most efficient extracting instru- 
ment in use ; and the improvements made in them 






300 EXTRACTION OF TEETH. 

during the last few years have been very great ; 
indeed, twenty years ago, they were not made with 
any special adaptation whatever, and were totally 
unfit to be used for the extraction of teeth ; but now, 
they are constructed with such various shapes and 
curves as to facilitate their approach to teeth' having 
any position in the mouth, and to fit all the forms of 
the points, and make the most perfect embrace of the 
tooth possible. Forceps, with the present improve- 
ments, take a deeper and more thorough Tiold on the 
teeth than any other instrument. The beaks may 
be made so thin that they will penetrate between the 
fangs and alveolus, and the adaptation so complete 
that the instrument will not slip its hold on the tooth 
at all. The form of the beaks should be such as to 
fit the crown without pressing on it, and yet perfectly 
embrace the neck of the tooth ; and the entire instru- 
ment of such form and curve as to give to the hand, 
arm, and body of the operator the best position for 
ease and facility of execution. 

There are various opinions as to the position rela- 
tive to the patient which the operator should occupy 
while extracting teeth with the forceps. Some re- 
commend different positions for the removal of differ- 
ent teeth ; but it is preferable, on many accounts, to 
occupy as nearly as possible the same position in the 
removal of all ; and this is at the right and a little 
back of the patient. 



FORCEPS. 301 

The forceps for removing the superior incisors are 
straight, and have thin beaks, which are sufficiently 
broad to embrace the anterior and the posterior sur- 
faces of the teeth entire (Fig. 39) ; and they should 
be much broader for the centrals than for the laterals. 

Fisr. 39. 




The points should not be so broad, however, as to 
come in contact with the contiguous teeth in the 
rotary motion made to break up the attachment. 
The same principle in regard to the width of the for- 
ceps is to be observed for the lateral incisors and 

V 

cuspids. The ordinary straight root forceps may be 
employed for the extraction of the lateral incisors; 
though, for this purpose, it is desirable that their 
beaks be somewhat thinner than usual. For the 
superior cuspid teeth, the ordinary bicuspid forceps 
are frequently used ; but their beaks are commonly 
too narrow, and those of the central-incisor forceps 
too thin. The cuspid forceps should be about as 
wide as those for the central incisors, with the thick- 
ness of the bicuspid forceps (Fig. 40), and with a 






302 



EXTEACTIOX OF TEETH. 



greater concavity, so as to fit the neck of the tooth. 
Superior bicuspid forceps have narrow, thick, and 



Fig. 40. 




quite concave beaks, and the instrument is straight, 
or nearly straight ; though for the second bicuspids, 
especially in a small mouth, it should have some 
anterior curvature. (Fig. 41.) One pair of forceps 
will serve for both sides, though it is desirable to 

F'lcr. 41. 




have one for the first, and an other for the second 
bicuspid. For the removal of the bicuspids, there is 
a kind of forceps with thick, smooth beaks, and of 
such a form as, by pressure, to force the tooth from 
its socket, taking advantage, for this purpose, of the 
conical form of the root. The superior molar for- 



FORCEPS. 



303 



ceps, a pair for each side, have one of the beaks a 
single concave, to embrace the palatine fang, and the 
other a double concave, with a projecting point from 
the center of the beak, to pass into the bifurcation, 
and with the edge of the beak so formed as to em- 
brace the two palatine fangs. The concavity and 
curvature of the beaks should be first just sufficient 
to accommodate the crown of the tooth. These for- 
ceps should have a double curve, to facilitate their 
approach to the teeth — an anterior curve just above 
the joint, and a downward curve just below it; 
sometimes, also, a lateral curve above the joint, 

Fisr. 42. 




throwing the instrument more toward the angle of 
the mouth. (Fig. 42.) 

For the second molars, the forceps should have a 






304 



EXTRACTION OF TEETH. 



little more curve above the joint, than for the first. 
A third pair of forceps for these teeth, and especially 
for the roots before they are separated, have the inner 
beak similar to the one above, and the outer a 
curved, attenuated, sharp point, to pass between the 
buccal fangs (Fig. 43). The forceps for the superior 

Fig. 43. 




dens sajnentice have two single-concave beaks, made 
to embrace the tooth, as though it were cylindrical, 
or nearly so, at its neck. The instrument has two 
curves, or rather angles, the one forward, and the 
other downward, so that its handle is somewhat an- 
terior to, but almost parallel with, the axis of the 
tooth. (Fig. 44.) It is a principle that should be 



FORCEPS. 



305 



observed in all forceps, that the handle be as nearly 
parallel with the axis of the tooth as possible, and as 



Fte. 44. 




nearly in a line with it as the location of the tooth, 
the size of the mouth, and other circumstances will 
admit. 

The forceps for the inferior incisors may have 
either a lateral or a transverse curve — almost to a 
right angle, if transverse, but if lateral, not more 

Fig. 45. 




than half that inclination. (Fig. 45.) The ordi- 
nary, slightly curved root forceps may be used for 






306 



EXTRACTION OF TEETH. 



the extraction of these teeth. (Fig. 46.) The 
beaks should be very narrow and thin ; for a great 



Fig. 46. 




amount of force is not required for the extraction of 
these teeth. The beaks of the inferior-incisor for- 
ceps should be relatively broader than those of the 
forceps for the superior incisors. Rotary motion in 
the extraction of inferior incisors, is not admissible. 




The inferior-bicuspid forceps are well adapted to the 
removal of the cuspids also. These forceps, two in 



FORCEPS. 



307 



number, one for each side, are of different forms. 
(Fig. 47.) The beaks are narrow, thick, and quite 
concave. The instrument for the right side has a 
lateral curvature, which brings the handle out at the 
angle of the mouth, and is necessary in order to ob- 
viate a contact with the superior teeth. The forceps 
for the left side have beaks of the same form. They 
are bent to almost a right angle above the joint, 
while below it the handle is thrown upward ; and 
their inner beak is longer than the outer. The infe- 
rior-molar forceps are two in number, that for the 

Fiff. 48. 




right side being curved outward and forward, and 
that for the left forward and upward, the beak making 
almost a right angle with the body of the instru- 



308 EXTRACTION OF TEETH. 

ment, and the inner beak of each being longer than 
the outer. The beak should be of sufficient breadth 
to embrace the entire side of the tooth, of double- 
concave form, with a ridge and a long point in the 
center of the beak, to pass into the bifurcation of the 
fangs. The inner beak of these forceps should be 
longer than the outer ; for the teeth on which they are 
designed to operate, have an inward inclination, and 
the outer alveolus is higher than the inner. (Fig. 
48.) 

A pair of forceps for the left side, similar in form 
to those for the right, would be preferable to the 
ordinary left forceps, w T hen the mouth can be opened 
wide ; and the curvature of the handle of this instru- 
ment would be toward the center of the mouth, in- 
stead of outward, as that of the right forceps. With 
this form of forceps, more power can be exerted than 
with the ordinary left inferior forceps. 

Forceps for the removal of the inferior dens sapi- 
ential have large single-concave beaks, to make a 

Fiff, 49. 



general embrace of the tooth, and have but one 
curve, which is between the joint and the point, and is 



FORCEPS. 309 

almost a right angle. (Fig. 49.) One pair of forceps of 
this kind is quite sufficient for both the right and the 
left side. The forceps denominated Physics forceps 
are also sometimes employed for the removal of the 
wisdom-teeth. These are constructed with thick, 
sharp blades, the edges of which come squarely 
together, and the points sometimes have an enlarge- 
ment on them. They are curved almost to a right 
angle : without this curve, the edges would be 
parallel with the handle. (Fig. 50.) There are two 
or three different forms of Physic's forceps. 

Fig. 50. 




Of the considerable variety of root forceps now used, 
those for the removal of the anterior teeth, are 
straight, or but slightly curved, with long, thin, 
sharp-edged beaks, and of a width regulated by the 
size of the roots. Those for the removal of the roots 
of the superior molars, when these are separated, 
have the same form of beaks as those for the front 
teeth, but more curved, to facilitate their approach to 
the roots. For the removal of these roots, it is well 
to have several pairs of forceps with different degrees 



310 



EXTRACTION OF TEETH. 



of curvature, using, in any given case, those with the 
least admissible curve — which, in a small mouth, 
will be considerable, while in a large one, it will be 
very slight. The same forceps that are used for the 
removal of the front inferior teeth, are applicable to 
the removal of their roots. 

Of the different forms of forceps for the removal of 
the roots of inferior molars, those for the extraction 
of the roots before they are separated, and while they 
are firmly attached, have two long, slender, round, 
curved beaks, designed to pass down deep between 
the two roots; their curvature should be almost a 
right angle, and their handles assume the form of 

Fig. 51. 




the ordinary right and left inferior-molar forceps, 
already described (Fig. 51) ; or, if but one is used, 



ELEVATORS. 



311 



the handle should be straight. The forceps for the 
removal of these roots after they are separated, 
should have the beaks of the same form as those of 
the superior-root forceps; but the beaks should be 
curved to a right angle with the handle, and the 
handle be straight. (Fig. 52.) 

Fig. 52. 




ELEVATORS. 

There are in use variously formed instruments 
constructed on the principle of the elevator. They 
are made with such points as to take the most tho- 
rough hold on the teeth or roots on which they are 
to be used, and with such curvature of shaft as to 
enable them to pass most readily to the desired posi- 

Fig. 53. 




tion. Some are so formed at the points as to em- 
brace the root at the border of the alveolus, using 



312 



EXTRACTION OF TEETH. 



the latter as a fulcrum (Fig. 53) ; others, to pass 
between the alveolus and the root (Fig. 54) ; others, 
to cut through the alveolus, and thus approach the 



Fig. 54. 




root. All the ordinary elevators make a fulcrum of 
the alveolus or of an adjoining tooth ; but some ope- 
rators, in using this instrument, contrive to make a 
fulcrum of the thumb or one of the fingers ; which 
is the preferable way. 

HOOKS. 

These are formed so that the point shall embrace 
the root and remove it, without any rest on the sur- 
rounding parts. The root is removed simply by 

Fijr. 55. 




pressure, applied in the proper direction. Of the 
various forms of this instrument, there are the for- 



SCREW. 



313 



ward hook, the backward (Fig. 55), and the corn, 
pound (Fig. 56), which last includes the former two, 



Fig. 56. 




These are valuable instruments, but require care in 
order to avoid injuring the surrounding parts. 



SCREW. 

This is a cone-shaped instrument, with a very 
definite, sharp screw-thread on it ; and the manner 
of using it in the operation of extraction is, to screw 
it into the fang. It will be required to be of various 
sizes to correspond with those of the different roots 
to be extracted. It is commonly attached to the 
handle by a permanent shaft (Fig. 57) ; but, some- 

Fiff. 57. 




times, it is made with a square shaft fitted into a 
socket handle (Fig. 58), by which arrangement the 



314 



EXTRACTION OF TEETH. 



handle is used only to introduce the screw ; and this 
serves only as a support to a frail root, the forceps 



Fig. 58. 




E&> 



being then brought to bear, in connection with it, for 
the removal of the fang. A screw-top, of the same 
form as the screw, should accompany it. 

When the screw is combined with the forceps, for 
the purpose of supporting the root and preventing 
it from crushing while it is removed with the forceps, 
the latter is of the same form as that of the ordinary 
straight-root forceps, with the shaft of the screw at- 
tached in the joint. In some, the screw is attached 
with a spring and ratchet, so that it can be drawn 
out, seized between the beaks, and introduced into 



Fisr. 59. 




the root ; and then these are slipped on the root, 
w r hich they embrace and remove. In others, the 
screw is fixed ; but the movable screw is to be pre- 



GUM-LANCET. 315 

ferred. (Fig. 59.) An arm bearing a pad, to rest as 
a fulcrum on the other teeth, is sometimes attached 
to- the shaft of the screw; but this is objectionable 
because of its liability to impede the action of the in- 
strument, and also to injure the adjoining teeth. 

GUM-LANCET. 

Of the various forms of the gum-lancet, the most 
common is that with the round point, and with the 
blade from two to four lines wide, and from half an 
inch to an inch long, attached to a shaft and handle ; 
the whole being about six inches in length. The in- 
strument should have a keen edge on the sides, two 
or three lines from the extreme point. It is some- 
times made with the edge square; but the round 
edge is the better form. The edge is parallel with 
the handle in the ordinary lancet. (Fig. 60.) This 

Fig. 60. 




form is used for separating the gum from the buccal 
and palatal surfaces of the tooth. A lancet with the 
edge transverse to the shaft is required for separating 
the gum from the proximal portions of the teeth. 
The blade of this should be of the same general 



316 



EXTRACTION OF TEETH. 



form as that already described, except that it should 
be quite narrow — in no case more than two lines 
wide. (Fig. 61.) Gum-lancets are made with the 



Fior. 61. 




blade set in a socket on the end of the shaft, so that 
it can be rotated and set to any angle, to meet every 
case. 

A very ingenious instrument, invented by Dr. 
Merry, and denominated " Merry's Revolving Gum- 
lancet," has recently been brought to the notice of 
the profession. This is a very excellent instrument 
— superior, indeed, to any thing else of the kind. 
(Fig. 62.) The following is a description of it : " It 
consists mainly of two shafts : one is round and 

Fisr. 62. 




small ; the other is larger, and part round, and part 
octagon. Just back of the spiral spring which curves 
down at the lancet end, is seen a piece connecting 



METHOD OF LANCING THE GUMS. 317 

the two shafts. This piece is soldered fast to the 
round shaft, while the upper end of it forms a collar, 
in which the round part of the larger shaft slides 
back and forth, and revolves. On the other end of 
the large shaft is seen a screw, made by winding a 
wire spirally round it. This is the male screw. 
From the small shaft rises an other, but shorter 
spiral wire, which, it will be seen, fits in the male 
screw. The short one may be considered the female, 
or nut, in which the other revolves. The ends of 
the short spiral are soldered fast to the small shaft. 
If, then, the large shaft is revolved, the screw on it 
playing in the female, is made to slide back and 
forth, accordingly as it may be revolved. This 
motion, then, changes the direction of the point of 
the lancet to the plane of the shafts, any degree from 
a right angle to a parallel. Having thus got the in- 
clination which is desired, the blade is inserted into 
the gum at the point at which the incision is to 
begin ; and as the instrument cuts, rotate the larger 
shaft slightly, and the blade will follow the outline 
of the tooth as it cuts round it." 

THE METHOD OF LANCING THE GUMS. 

In all cases, the gum should be separated from the 
tooth as far as the embrace of the forceps is to ex- 
tend ; and the lancet should pass close to the tooth, 



318 EXTRACTION OF TEETH. 

so as to make the separation clean about its neck ; — 
in ofder -to which, the lancet must be kept in good 
condition ; — and it should also be passed freely 
between the teeth. A complete separation of the 
gum is essential to a good hold of the forceps on the 
tooth. Some operators, however, do not use the 
lancet for this purpose, but tear the gum away by 
forcing the forceps to its position on the tooth. This 
method is objectionable on several accounts: it causes 
the patient much more pain than with a sharp 
lancet ; the forceps can not thus be adjusted to the 
tooth with so much facility ; there is far more danger 
of lacerating the soft parts, and, because of an imper- 
fect adaptation of the forceps to the tooth, more 
danger of fracturing this; and the operation is always 
more difficult of accomplishment. In those cases in 
which the gum is firm and tense, and would obstruct 
the free passage of the forceps to the proper position 
on the tooth, it is sometimes necessary to make a 
vertical incision of the gum, even after it has been 
separated, directly opposite the fang. But it is in 
many instances better to cut away a portion of the 
free margin of the gum, in the extraction of roots 
that are partially covered by it; and there is no 
objection to this method in any case where it may 
at all facilitate the operation ; for this portion of the 
gum, if let remain, is always absorbed away after the 
extraction of teeth. It is also sometimes necessary 



EXTRACTION OF TEETH. 319 

to dissect the gum somewhat from the alveolus in 
those cases in which a deep hold on the tooth or root 
is required, and in which the alveolus is either cut 
away or embraced by the forceps. The character 
and condition of the tooth will somewhat modify the 
extent to which the gum-lancet should be used. 



EXTRACTION OF THE TEETH. 

In the following remarks, it is the design to con- 
sider only those principles obviously involved in the 
extraction of the teeth with forceps, and in the ex- 
traction of roots with forceps, elevators, and screws. 

Superior Incisors. — After an examination, the gum, 
as in all cases, should be perfectly separated from the 
neck of the tooth, up to the border of the alveolus : 
this is quite sufficient, if the tooth is not too much 
decayed. With the forceps already described (see 
Fig. 39), grasp the tooth firmly at the border of the 
alveolus; introduce the instrument slowly, adjusting 
it carefully, as it passes up to the proper position ; 
then, by a gradual movement, rotate the tooth in the 
socket, thus breaking up the attachment. All the 
cylindrical, single-fang teeth may be luxated by a 
rotary motion. There are occasional circumstances, 
however, that render this somewhat difficult, — as, for 
instance, any considerable curvature of the root ; or, 
sometimes, the attachment to the outer plate of the 



320 EXTRACTION OF TEETH. 

alveolus is so firm that it can not be broken up by 
rotary motion. Neither of these difficulties is usual 
with the lateral incisors ; but, with the centrals, one 
or other of them is not unfrequent. When either of 
them does occur, the attachment must be broken up 
by an inward and outward movement, which, on 
account of the pressure made on the parts, is 
attended with much more pain, and far greater 
danger to the contiguous parts, than the loosening 
by rotary motion. 

The roots of the incisors are not difficult to remove, 
unless, being very much decayed, they will not sus- 
tain the embrace of the forceps below the border of 
the alveolus ; and when they are thus decayed, one 
of the following methods may be adopted : the gum 
may be dissected on the alveolus, and the latter cut 
away with the thick cutting instrument, so as to 
expose the root sufficiently for extraction with the 
root forceps ; or, after the gum is dissected up, the 
alveolus and the root may be together embraced, and 
the former broken away with the latter. This is a 
rather rough method of operation, though it is often 
adopted. Or, an elevator of the proper form may be 
introduced between the root and the alveolus, and 
the root thus dislodged. 

The screw, either simple or compound, is a valuable 
instrument for the removal of these roots. But the 
gum should be separated even when the extraction 



EXTRACTION OF TEETH. 821 

is to be accomplished with this. The canal in the 
root should first be enlarged with a taper drill, of the 
same shape as the screw, till all the softened dentine 
is removed. Then the screw, selected of proper size, 
and with a very sharp and firm thread, is introduced 
till it takes a strong hold in the solid dentine, espe- 
cially if it is the simple screw. In some instances, 
while it is being introduced, the root will be loosened. 
In using the screw in connection with the forceps, it 
is not necessary to introduce it with the same firm- 
ness as when the screw alone is employed. In the 
use of the screw-forceps, the screw is embraced in 
the beaks, and introduced ; then, the forceps are 
passed up on the root, or between it and the alve- 
olus, if need be, the screw serving to sustain the root 
under the pressure of the forceps. The attachment 
of the root is broken by a rotary, or an inward and 
outward movement, as the case may require. 

Superior Cuspids. — For the removal of these teeth, 
the central-incisor or the bicuspid forceps may be 
used; though usually, the beaks of the former are too 
thin, and those of the latter, too narrow. The for- 
ceps appropriate for the removal of these teeth, have 
broad, deep, concave beaks, so as to embrace the tooth 
as completely as possible ; and they are thick, so as 
to possess sufficient strength. The gum being sepa- 
rated, and the forceps adjusted on the tooth, the at- 
tachment is broken up, either by an inward and out- 



322 EXTRACTION OF TEETH. 

ward, or by a rotary movement ; the former will be 
far more frequently brought into requisition, since 
these teeth are generally so firmly attached that 
they can not be loosened by the latter ; but the skill- 
ful and experienced operator will often combine the 
two, with the happiest effect. These teeth have 
larger roots than any others in the mouth, and the 
alveolar process closely invests them ; and thus they 
are very firmly fixed in the sockets, and are also 
more frequently found curved than the roots of the 
incisors. Often, in extraction of the cuspids, a por- 
tion of the outer wall of the alveolus is broken off, 
and comes away with the tooth. But this accident 
is not attended with any serious results ; indeed, in 
the preparation of the mouth for artificial teeth, it is 
desirable that it be broken away. 

The movement in the extraction of a tooth should 
always be very deliberate — never sudden and violent. 
A very good criterion in regard to the rapidity of 
movement, is, that the eye should follow and dis- 
tinctly recognize every motion of the forceps, the 
tooth, and the contiguous parts. 

The removal of the roots of these teeth is far more 
difficult than that of the incisors. Frequently the 
gum has to be separated up two or three lines on the 
alveolus, and the latter broken in with the forceps, 
before the root is removed. The compound screw is 
often very valuable in the removal of these roots — 



EXTRACTION OF TEETH. 323 

the simple screw not commonly being of much avail, 
since the force necessary to extract the root, is gene- 
rally so great that the screw alone will not take a 
sufficiently firm hold to accomplish it. The elevator 
is not a very efficient instrument in the removal of 
these roots. 

Superior Bicuspids. — For the removal of the bicus- 
pid teeth of both sides, one pair of forceps is quite 
sufficient (see Fig. 41). These forceps are without 
any curve ; though, in a small mouth, for the second 
bicuspids, a slight anterior curve would be desirable, 
since it would admit the instrument to a better position 
on the tooth. These forceps properly adjusted on the 
tooth, according to the directions already given, the 
attachment is broken up by an inward and outward 
movement, carried just to the extent necessary to 
accomplish the object ; and then, traction is applied 
to remove the tooth from the socket. This applica- 
tion of the force is specially adapted to the first 
bicuspids. Rotary motion should be very seldom 
applied to these teeth, because their points generally 
terminate in a bifurcation, and it is impracticable 
thus to detach them without breaking off, at least, 
one of the fangs ; and, where these fangs do not bifur- 
cate, they are so much compressed as generally to 
forbid such a force. Occasionally, however, there is 
but one fang, and this is nearly cylindrical, as will 
be indicated by the cylindrical form of the crown 



324 EXTRACTION OF TEETH. 

and neck of the tooth ; and, in such cases, the rotary 
may be combined with the inward and outward 
motion. The roots of the second bicuspids com- 
monly terminate in one conical fang, usually some- 
what compressed ; and, in general, the rotary motion 
may be combined with the inward and outward in 
their extraction. There is occasionally, however, 
some curvature to these roots ; but very seldom is it 
sufficient to cause any difficulty in their removal. 
The skillful and experienced operator will, in most 
cases, determine very accurately the size, shape, and 
position of the fangs by the peculiarities of the 
crown ; and the attention of the young practitioner 
should be directed very closely to this point, till he 
is able to arrive at accurate conclusions. For the 
removal of these teeth, there are forceps with thick, 
peculiarly-formed beaks, constructed to take advan- 
tage of the conical form of the roots. The instru- 
ment is placed on the tooth at the border of the alve- 
olus, or, if need be, a little beyond it ; and then, the 
process having been first cut awa}~, firm compression 
is made on the handle of the instrument, and thus 
great pressure on two sides of the root, — which are 
relatively as two inclined planes, — by which the 
tooth is forced directly from its socket, without 
either the oscillating or the rotary motion. This 
instrument is rarely ever applicable to the removal 
of any other teeth than the second bicuspids, and 



EXTRACTION OF TEETH. 325 

occasionally the central incisors, and then only 
when the roots are very tapering. The roots of the 
bicuspids, especially the second, are usually not diffi- 
cult to remove. Sometimes, however, the first bicus- 
pids have two well-formed roots, somewhat divergent, 
that are difficult to remove, especially if the decay 
has eaten away till there is little of the tooth left for 
the instrument to take hold upon. But, frequently, 
if one of the contiguous teeth is absent, a lateral 
seizure will remove the root at once. 

Root forceps with narrow, thin beaks, which may 
be readily forced between the root and the alveolus, 
are very valuable for the extraction of all small 
roots. 

The screw, whether simple or compound, is not ap- 
plicable to the extraction of the roots of the bicus- 
pids. 

A bicuspid will sometimes stand somewhat out of 
the true circle, and the contiguous teeth approximate 
so that it will not pass between them. In such a 
case, the principal part of the movement for its de- 
tachment should be in the direction of its inclination. 
The cuspid teeth are sometimes found in the same 
condition, and a similar application of force for their 
removal is to be made ; indeed, this method is appro- 
priate to all cases where the teeth stand out of a 
proper position and the contiguous teeth impinge on 
the space. 



326 EXTRACTION OF TEETH. 

Superior Molars. — The first and the second superior 
molars have each three fangs, one buccal, and two 
palatal ; the palatal being the largest and longest, 
and the buccal of the first larger than that of the 
second. The palatal fangs diverge very considerably 
from the axis of the tooth ; while the buccal are 
often parallel with it and with each other ; but they 
sometimes diverge in both directions. Occasionally, 
the divergence of some or all of these fangs, is so 
great that they can not pass out of the socket with- 
out either fracturing the alveolus or breaking oft" one 
or more of the roots. On the contrary, there Lb 
sometimes such a convergence of the buccal fa 
that the intervening portion of bone is neces.-arily 
brought away with the tooth. Indeed, the three 
fangs are sometimes found all in contact, forming 
irregular conical root ; but this is a condition of un- 
natural development. 

The appropriate forceps being (irmly iixed on the 
tooth, an outward and inward movement is applied, 
and traction at the same time. In the examination 
of these teeth, to ascertain the force necessary for 
their removal, two particulars have to be considered : 
the firmness of the attachment, and the position and 
inclination of the roots. When these teeth, as they 
occasionally do, stand somewhat outside ^( the cor- 
rect position, great care must be exercised in their 
removal, especially if the contiguous teeth imp: 



EXTRACTION OF TEETH. 327 

In small mouths, the contiguous impinging tooth is 
liable to be injured by the pressure in extraction ; but 
this injury may be avoided by directing the pressure 
backward. Commonly, the first effort made to break 
up the attachment, should be outward ; except where 
the tooth stands inside of the circle, or w r here it is 
decayed very much on its inner side, while its outer 
remains firm. In those cases in which the fangs 
diverge so much that they will not pass out of the 
socket, without tearing away some of the wall of the 
alveolus, it would be impossible to break up the at- 
tachment by an inward movement ; for the palatal 
fangs brace the tooth, and the inner process is very 
strong and unyielding. Where a molar is decayed 
on its proximal sides, and the contiguous teeth en- 
croach on it, so that it can not pass out directly be- 
tween them, it must either be cut away with the 
chisel or file till it is small enough to pass, or be 
drawn to the outside from between. 

The decay on the buccal or palatal sides often 
extends below the gum, and even below the border 
of the alveolus ; or there may be extensive softening 
of the dentine of the crown ; and in either case, the 
gum and process must be cut away sufficiently to 
admit a firm hold on the tooth where it is strong 
enough to sustain the embrace of the forceps. 

Extraction of Roots.— The extraction of the roots 
of the superior molars is not attended with much 



328 EXTRACTION OF TEETH. 

difficulty when they are separated by decay, or are 
easily broken apart ; the method then is the same as 
for single roots. They should be deeply embraced 
with the curved, sharp-pointed root forceps (see Fig. 
46), and rotated to break up the attachment, trac- 
tion being applied at the same time. It is very 
rarely necessary to resort either to the elevator or to 
the screw for the removal of these roots. The 
greatest difficulty is experienced when the bifurca- 
tion is deep, and the roots all adhere firmly together. 
In such case, the same force is required for their 
removal as before tbe crown was decayed off. The 
root forceps, shown in Fi_r. I-'), can be very effect- 
ively used in the extraction of these roots. The 
round, sharp beak is passed between the buccal and 
the palatal fangs, the other beak embracing the 
palatal ; and with this hold, by an inward and out- 
ward movement, the root is removed. These forceps 
# are not applicable where there is but one large coni- 
cal root. For the removal of roots of this form, the 
wisdom-tooth forceps, or those with similar b 
are required. When it is necessary to dissect off the 
gum, and cut away the process, in order to obtain a 
firm hold of the root, this should be done in preference 
to crushing in the process with forceps — except, indeed, 
it may be the case oi^ a very irritable patient, who will 
not tolerate a protracted operation; in which case, it 
is better to complete the operation at a single effort. 



REMOVAL OF THE DENTES SAPIENTL&. 329 

REMOVAL OF THE DENTES SAPIENTIjE. 

There is not usually much difficulty attending the 
extraction of these teeth. The appropriate forceps 
for this purpose (see Figs. 44 and 49) have two large 
single-concave beaks, so formed as to embrace the 
neck of the tooth, without any reference to the bifur- 
cation or the number and position of the fangs. 
Ordinarily, the attachment of these teeth is broken 
up by the inward and outward movement;' but 
where a single, round, conical root is clearly indi- 
cated, the rotary movement would be preferable, or 
the rotary in conjunction with the inward and out- 
ward. These teeth sometimes stand out of the true 
position, more frequently inclining outward, as 
already suggested in an other place ; and the direc- 
tion of the force for their extraction will correspond 
with this inclination. 

Sometimes these teeth are very difficult to extract ; 
and this difficulty is dependent on the following cir- 
cumstances : first, an anterior inclination of the 
tooth, so that it stands at a considerable angle with 
the adjoining tooth/ and in contact with its posterior 
proximal surface, the posterior border of the process 
being thick and firm, and extending down full on the 
crown of the tooth; and second, the existence of 
several fangs, with great divergence, irregularity, 
and curvature. The removal of a tooth in the first 



330 EXTRACTION OF TEETH. 

of these conditions is often a very protracted opera- 
tion, 'fraught with much pain to the patient and con- 
siderable labor to the operator. Such preparation 
must be made as will permit a free egress of the 
tooth from the socket, before an effort is made for its 
extraction. This is effected either by cutting away 
the portion of process behind the tooth, so that it 
may be forced backward sufficiently to let it pass out 
of the socket, or by cutting away enough from the 
anterior portion of the tooth; or, if the posterior 
proximal surface of the second molar is decayed, it 
may be quite as well, and more convenient, to cut 
this down so as to allow of the egress. 

Physic's forceps can be used very effectively for the 
extraction of these teeth, when they occupy such a posi- 
tion, provided the root is straight, or has a posterior 
curvature ; but if there is an anterior curvature, the 
tooth is most difficult to extract, and Physic's for 
would be wholly inefficient— except to break off the 
tooth. In such case, the posterior portion of the 
process should be cut away as much as possible. 
Physic's forceps are frequently employed for the 
removal of these teeth, when they occupy a correct 
position ; but their use is somewhat objectionable, 
especially in the following respects : the instrument 
acts first on the principle of a wedge, being forced 
between the teeth, and then on that of a lever, the 
second molar being the fulcrum ; and hence, when it 



INFERIOR INCISORS. 331 

is employed, the second molar must always be pres- 
ent, and is liable to injury from the pressure which 
may do violence to the periosteum, or fracture and 
scale off portions of the enamel. But if the first 
molar is absent, there is almost as much liability, 
with the forceps, of loosening the second as of ex- 
tracting the third. Indeed, it is always objectionable 
to use a sound tooth, under any circumstances, as a 
fulcrum for an extracting instrument. 

When the roots of a wisdom tooth are irregular in 
number, inclination, and curvature, a good firm grasp 
must be taken on it, and then an oscillating force 
applied, sufficient to remove it from its socket. 
There is nothing pertaining to the removal of the 
roots of these teeth that involves any different prin- 
ciple or application of instruments from that given 
for the removal of the teeth themselves. The ante- 
rior inclination which so often renders the whole 
tooth difficult of extraction, very seldom affects the 
removal of the roots. These are, in general, easily 
extracted with the common curved-root forceps. 

EXTRACTION OF THE INFERIOR INCISORS. 

In the extraction of these teeth, either of the for- 
ceps described for the purpose, may be employed. 
The beaks should be quite narrow and thin (see Fig. 
45). The instrument well fixed on the tooth, the 



332 EXTRACTION OF TEETH. 

attachment is broken up by the inward and outward 
movement, the rotary being seldom applicable, since, 
in general, the roots are flattened, and in many cases 
quite thin, so as to be incapable of turning in the 
socket. Care must be exercised in the oscillating 
movement, and especially where the tooth to be ex- 
tracted stands out of the proper position, and the con- 
tiguous teeth incline together ; though this is of little 
consequence where the teeth are all to be removed. 
When the crowns of these teeth are short and thick, 
the roots are shorter, thicker, more conical, and more 
nearly cylindrical ; and, in the extraction of such, the 
rotary may be combined with the oscillating movement. 
Roots. — There is seldom any superadded difficulty 
in the removal of the roots of these teeth, the same 
instruments and movements being applicable as to 
the removal of the teeth themselves. The only dif- 
ference in any respect is, that where the teeth are 
decayed off far down, the forceps should be forced 
down on the process, in order to obtain a firm hold 
on the root. Neither the elevator nor the screw is 
ever required for the removal of these roots. 

INFERIOR CUSriDS. 

These teeth may be removed with the inferior-bicus- 
pid forceps of the right side ; though an instrument 
of the same general form, but of less curvature would 



INFERIOR CUSPIDS. 333 

be preferable, since with such, the required movement 
for breaking up the attachment could be more easily 
given. They commonly have long, round, conical 
roots, not so large as those of the superior cuspids, 
nor so difficult to extract — seldom having any curva- 
ture, and thus being susceptible of detachment by the 
rotary motion. They often stand so much anterior 
to the true circle, that an attempt to thrust them in- 
ward, would be liable to break or loosen the lateral 
incisors. Their situation, as indeed that of all teeth, 
should be strictly attended to before any attempt is 
made to remove them. 

The crowns of these teeth decay ofT, and leave the 
roots standing, for more frequently than do those of 
the superior cuspids. But there is no difficulty in the 
removal of their roots ; and the only indication is, 
when they are deeply decayed, to pass the forceps far 
down on them, either first cutting away the process or 
embracing it, as the circumstances may warrant; the 
former method being preferable. After the root is 
extracted, the fractured pieces of process, if any, 
should be removed. 

A long, tapering screw may sometimes be advan- 
tageously used for the extraction of these roots, when 
they are decayed so deeply that an extensive break- 
ing-away of the process would be incident to their re- 
moval with the forceps. The elevator, however, is 
rarely ever called into requisition here. 



334 EXTRACTION OF TEETH. 



INFERIOR BICUSPIDS. 



These teeth, two in number on each side, have but 
one fang, and that generally round, or nearly so, and 
not so long as that of the cuspids ; and have less diam- 
eter at the neck than they. They require, in ex- 
traction, forceps for each side, as already described 
(see Fig. 47). They may be removed either by the 
rotary, or by the inward and outward movement, or 
by both combined. With the handle of the forceps 
thrown very far out of a line with the axis of the 
tooth, this is always more difficult to be rotated ac- 
curately in its socket ; a straight instrument is best 
for the rotary motion. In the removal of these teeth 
from the right side, when the mouth is small, care 
should be taken that too much pressure is not made 
against the anterior tooth. This accident is more 
liable to happen in the removal of the second bicus- 
pid, than in that of the first, and especially if the 
mouth can not be opened wide. As the tcoth comes 
out, the forceps are liable, without some attention 
strike the superior teeth, and in this way fracture 
them or scale off their enamel. In man . for- 

ceps with a forward and an outward curvature com- 
bined, would be very desirable, for facility of ap- 
proaching the tooth ; but with such a complication 
of curves, the operator loses control of the instru- 
ment. 



INFERIOR MOLARS. 335 

In the removal of the bicuspids of the left side, 
there is little or no liability to undue pressure against 
the anterior teeth ; and in their extraction, the move- 
ment should be mainly inward and outward, since 
the great curvature of the forceps renders a rotary 
motion very difficult and uncertain. There is also 
danger here of striking the upper teeth, especially if 
the tooth to be extracted comes out with less effort 
than the operator anticipated ; an accident that 
sometimes befals the most skillful and discriminative. 
The first and the second inferior bicuspids are re- 
moved with about equal facility. 

Occasionally, though seldom, these teeth have two 
distinct, well-defined roots ; a condition that can not 
be determined by the form of the crown or by any 
other visible indication ; and one tooth alone will 
sometimes be found with this peculiarity. The re- 
moval of the roots of these teeth is not attended with 
much difficulty ; the main consideration being, to ob- 
tain a deep, strong hold on them, and then apply a 
firm, steady movement. 

INFERIOR MOLARS. 

These teeth commonly have two fangs, a posterior 
and an anterior ; the latter being the largest, and fre- 
quently the longest. The roots have different incli- 
nations to the axis of the tooth, being in some cases 



336 EXTRACTION OF TEETH. 

divergent from, and in others parallel with it, and in 
other's convergent, or curved together so that their 
points almost meet. The forms of the crowns will 
give some indication of the inclinations of the fangs : 
if those are short, these are so, and vice versa ; if the 
diameter of the crown is about the same at the mas- 
ticatory surface and the neck, the fangs do not 
diverge ; if the crown is long and of uniform diam- 
eter, the fangs will be either parallel or convergent; 
and if the angles on the crown are not sharp and well 
defined, the roots most probably curve together at 
the points. If, however, the angles formed by the 
masticatory and lateral surfaces of the teeth are 
sharp and well defined, the roots generally diverge. 

Forceps adapted to each side are required for the 
removal of these teeth. These forceps have a promi- 
nence, or point, in the center of the beaks, to pass 
into the bifurcation; and, in separating the gum, it is 
important to dissect it away, and, if need be, even 
cut away the margin of the process, so that the bifur- 
cation may be well exposed, to admit the forceps to 
a proper position on the tooth, without obstruction. 
The tooth being firmly grasped in the proper manner 
by the forceps, is moved gradually, but steadily, 
inward and outward, to break up the attachment, 
and then drawn from its socket. In the removal of 
these teeth from the right side with the ordinary for- 
ceps, there is great danger of undue pressure on the 



INFERIOR MOLARS. 337 

anterior contiguous teeth ; which is to be avoided by 
directing the pressure backward in the operation. 
And there is also danger of injuring the upper teeth 
with the forceps; which maybe obviated by wrap- 
ping the joint of the instrument with a small napkin. 

In the removal of the inferior molars of the left 
side, the application of force is the same — an inward 
and outward movement — but the handles of the for- 
ceps occupy different relative positions to the teeth 
to be extracted, passing directly out at the front of 
the mouth, in stead of at one side. In consequence 
of this arrangement, the operator can not exert the 
same force on them, as, with the proper forceps, on 
those of the right side. Very little traction can be 
employed in connection with the oscillating move- 
ment, but the attachment must be almost wholly 
broken up before beginning to lift the tooth from the 
socket. But in extracting the teeth on the right 
side, with the proper forceps, traction is always com- 
bined with the to-and-fro movement. 

In the extraction of the roots of these teeth, little 
difficulty is experienced after the decay has pro- 
ceeded so far as to effect their separation. They are 
then embraced with the appropriate forceps, and 
removed as single roots are elsewhere. These for- 
ceps have narrow, thin, sharp beaks, turned to almost 
a right angle. With them, the root is embraced, and 
moved inward and outward till loosened, and then 



338 EXTRACTION OF TEETH. 

removed. When the mouth is large, and can be 
opened wide, the slightly curved root forceps are 
convenient, and the rotary movement may be em- 
ployed with them, if the roots are not very much 
curved, flattened, or firmly set. The removal of 
these roots is more difficult when the bifurcation is 
low down, and the roots remain firmly attached to- 
gether, and especially when they diverge. If the bi- 
furcation is not too low, and the attachment not too 
firm, the roots may be separated with the -separating 
forceps (Fig. 63), and then removed singly, as in 
other cases. This is the preferable method, when 

Fig. 63. 




there is much divergence; but if the fangs can not 
be separated, they may be extracted with the forceps 
shown in Fig. 52. The round, curved, sharp beaks 
are passed down between the roots, and the whole is 
removed at once ; the attachment being broken up on 
the principle already described. 

These teeth sometimes have but one, large, round, 
conical fang; and there is seldom, if ever, enough 
curvature of the roots to render extraction difficult. 



INFERIOR DENTES SAPIENTI^. 339 

The ordinary inferior-molar forceps are not well 
adapted to the purpose; for the central points of 
their beaks will prevent a perfect adaptation. The 
broad, single-concave, beaked forceps are best adapted; 
the curves and general forms of which, except the 
beaks, are the same as those represented in Fig. 49. 
The removal of teeth with this kind of roots is easily 
accomplished. Rotary movement would be appli- 
cable here, if the exact form of the root could be 
ascertained before extraction; but it is, in general, 
the safest course to employ the inward and outward 
movement. 



INFERIOR DENTES SAPIENTIAL 

These teeth require, for their removal, the broad, 
single-concave, beaked forceps, the beaks curved at a 
right angle with the handle, and the handle straight. 
This instrument fixed deeply and firmly on the 
tooth, the attachment is to be broken up by the 
inward and outward movement. These, more fre- 
quently than the superior denies sapientice, stand out 
of the proper position ; their variations and the man- 
ner of obviating the attendant difficulties, however, 
being about the same — at least, so far as deviation is 
concerned. Physic's forceps may be used here with 
greater facility than on the upper teeth. 

These teeth frequently exhibit but a very small 



340 EXTRACTION OF TEETH. 

portion of the crown through the gum. Being 
erupted with an anterior inclination, the tooth comes 
in contact with the posterior portion of the second 
molar, and is thus checked in its external develop- 
ment. Thus the crown is left partially covered with 
the gum, which frequently inflames, and even sup- 
purates, remaining in that condition for a consider- 
able time, to the great annoyance of the patient. 
Such teeth are difficult to remove ; first, because of 
their inclination and contact with the second molar; 
and secondly, because the crown is more than half 
below the borders of the thick, firm alveolus, render- 
ing it impossible to obtain a firm hold of the tooth, 
without cutting away a portion of the alveolus. In 
such cases, it is generally best to make a free excision 
of the alveolus all round the tooth, sufficient to per- 
mit its easy removal. 



EXTRACTION PREPARATORY TO THE INSERTION OF 
ARTIFICIAL DENTURES. 

Whenever there is a number of teeth to be re- 
moved, the method and the duration of the operation 
will depend on the following circumstances : first, the 
number to be removed ; second, the firmness of their 
attachment; third, the patient's power of endurance; 
and fourth, the manner in which the immediate parts 
are affected. Where the number to be removed is 



EXTRACTION PREPARATORY TO INSERTION. 341 

considerable, and the attachment is feeble, or not 
very firm, and the patient's power of endurance good, 
the extraction may be as rapid as is consistent with 
efficiency. In many such cases, from three to six 
teeth may be removed, without any relaxation, by 
the operator, of his hold on the parts with the left 
hand. This is generally practicable with the front 
teeth of the lower, and frequently with those of the 
upper jaw ; but it is not proper to remove more than 
three or four of the molar teeth, without respite, even 
when they are quite loose, or have but a feeble 
attachment in the socket. The gum should, of 
course, be well separated previously to the operation. 
Only so many teeth should be removed at one sitting 
as the nervous system will allow without too great a 
shock. In many instances, however, it is practi- 
cable, so far as this is concerned, to remove at once 
all the teeth in the mouth. In the extraction of a 
large number, those most easily removed should be 
first taken, so as by degrees to bring the patient to 
severer operations. If there is a manifest hemor- 
rhagic diathesis — a disposition to bleed freely from 
the capillaries, as well as from the larger vessels — 
but two or three teeth should be removed at a sit- 
ting, lest uncontrollable hemorrhage ensue. 

After all the teeth are removed from one or both 
of the jaws, the gums and alveolus should undergo a 
trimming process : all detached, flabby, or prominent 



342 EXTRACTION OF TEETH. 

portions of the gums should be dissected off; the 
whole ridge made uniform ; all loose portions of the 
alveolus removed ; all the prominent points and sharp 
edges cut down ; and the whole border of the process 
rendered as smooth and even as possible. By this 
means, the healing of the parts is facilitated, and they 
assume the desired condition and form in much less 
time, and with far less soreness and inconvenience. 



CONDITIONS TO BE OBSERVED IN THE EXTRACTION. 

Such conditions are often found to exist in the 
system, as indicate the necessity of great care in the 
operation, or of prior treatment, or forbid the extrac- 
tion of the teeth altogether. Of these conditions, the 
following are some of the more obvious : 

Extreme debility. 

Great nervous irritability. 

Excessive local inflammation, especially where it 
tends to the other parts. 

Much irritability of the parts intimately connected 
with the teeth. 

Pregnancy, and all uterine irritations. 

A tendency to epilepsy. 

In many cases, where there is great debility, so 
painful an operation as the extraction of a tooth, will 
cause extreme, and sometimes alarming prostration. 
This, however, may be anticipated, by prior invigo- 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 343 

rating treatment, continued till strength and tone are 
obtained sufficient to endure the operation. This 
treatment may occupy considerable time; while an 
urgent case may arise, in which the removal of the 
offending tooth is immediately demanded ; in which 
case, it is proper to administer stimulants — brandy or 
wine, or such as the case may seem to require. By 
such means, the system may be so invigorated as to 
withstand the shock of the operation with compara- 
tive fortitude. 

There is in some cases a highly irritable condition 
of the nervous system, that almost absolutely forbids 
the extraction of teeth, convulsions being sometimes 
produced, in such cases, by a simple operation. This 
remark does not of course apply to facial neuralgia 
that may be either partially or wholly produced and 
kept up by diseased teeth ; neither general nor local 
neuralgia would be aggravated by an operation of 
this kind. Accompanying general nervous irrita- 
bility, there is usually excessive dread of an opera- 
tion, such as to occasion rapid prostration— even 
greater and more rapid than that caused by the ope- 
ration itself. In such cases, if the extraction is 
effected immediately, it will give relief; but where 
the excitement has been very high, and the tension 
for some time great, the depression after the opera- 
tion will be correspondingly great, and considerable 
time be required for complete recovery ; indeed, the 



344 EXTRACTION OF TEETH. 

shock is sometimes so severe as to occasion confine- 
ment for several days. Treatment for quieting the 
nervous system, consisting in agents of a sedative, 
nervine character, may be employed previously to 
the operation : stimulants, as a general rule, should 
be avoided. 

Where there is a high state of inflammation in the 
immediate parts, especially if there is a general in- 
flammatory diathesis, the propriety of extracting the 
teeth is questionable. Under such circumstances, 
there is probably less danger in the extraction of the 
inferior teeth, than of the superior. Where the in- 
flammation has a disposition to extend, it is liable to 
go to the head from the superior maxilla, and to the 
fauces and throat from the inferior. In cases, then, 
where there is excessive inflammation in the imme- 
diate parts, accompanied by a general inflammatory 
condition, both local and general antiphlogistic treat- 
ment should be adopted. 

Extreme irritabilitv, or a diseased condition of 
parts having an intimate connection with the teeth, 
as the immediate surrounding tissues, the salivary 
glands, and the throat, is a circumstance admonish- 
ing to great caution in the extraction of teeth, espe- 
cially when such condition does not depend on the 
teeth for its exciting cause or modifying influence. 
It is, however, very generally the case, when any of 
the parts having an intimate relation with the teeth, 



CONDITIONS TO BE OBSERVED IN EXTRACTION. 345 

become in any way affected, diseased teeth will exer- 
cise an injurious influence on them. If the necessity 
for the removal of the offending tooth is not too urgent, 
the parts that may be diseased about it, should be 
brought to as good a condition as possible. 

Pregnancy and uterine irritation frequently pro- 
duce strong sympathetic influences on the teeth, and 
especially on those which are in an irritable condi- 
tion : even sound teeth may be thus affected, so as to 
occasion great annoyance. Such teeth are frequently 
presented for extraction; but these cases should 
always be thoroughly examined before deciding as to 
the propriety of an operation. As a consequence of 
this sympathetic connection between the teeth and 
the uterus, the latter, when in an irritable condition, 
is very liable to be affected by any special violence to 
the former. In many cases, under such circum- 
stances, the extraction of a tooth is attended with 
pain in the uterus ; and in cases of pregnancy, where 
there is debility of the parts involved, abortion is 
liable to follow the operation. It is the duty of the 
patient, under such circumstances, to notify the ope- 
rator of the condition ; or, if the latter has any know- 
ledge of it, it is his duty to become fully acquainted 
with the circumstances, and then to conform to the 
indications. In such case, treatment will avail but 
little to prepare the system for the operation. The 
better method is to adopt palliative treatment; 



346 EXTRACTION OF TEETH. 

which, if the affection is wholly sympathetic, must 
be directed to the organ producing the difficulty. 
But if the affection is in part local, then topical treat- 
ment is also indicated. When there is a suppression 
of menstruation, there will be an increased disposi- 
tion to hemorrhage; and in the extraction of the 
teeth of a patient of hemorrhagic diathesis, this is a 
point to which observation should be very specially 
directed : here, of course, a remedy for the obstruc- 
tion would meet the difficulty. 

Persons subject to epilepsy should be very cau- 
tiously treated in all operations on the teeth, and 
most especially in their extraction. It is not pro- 
bable, however, that an operation of this character 
would increase the tendency to epilepsy; but any 
undue excitement is liable to produce a paroxysm of 
the disease ; and hence the operator should proceed 
to his work with as little parade as possible ; yet, not 
stealthily ; the patient should be thoroughly aware of 
what is to be done ; for, of all patients, such a one is 
the last that should be deceived. Of course, in a case 
of this kind, there can be no prior treatment that will 
avail anything; the most that can be done, is, to 
await the fittest opportunity in respect to the 
paroxysms. There is no more liability to fatal re- 
sults with such patients than with others. 



CHAPTER XII. 

ACCIDENTS IN THE EXTRACTION OF TEETH. 

The accidents liable to occur to the teeth and the 
contiguous parts in the operation of extraction, used 
to be far more frequent than they are at present. 
This difference results from the existence of more 
perfect instruments and of more accurate and exten- 
sive knowledge. Formerly, no one studied the pecu- 
liarities of the teeth, either in their physical or ana- 
tomical structure ; their peculiar forms, as indicated 
by their crowns ; their anatomical and physiological 
relations to the contiguous parts and to one an other ; 
and their attachment as affected by the character and 
structure of the tissues about them. The instruments 
employed, too, were, till within a few years past, very 
crude in their forms, very inapplicable in that part 
which embraces the tooth, inappropriate in their 
shapes, and defective in their manner of applying the 
force in the operation. But these causes of accidents, 
so far as the better part of the dental profession is 
concerned, have been in a very marked degree dimin- 
ished. 



348 ACCIDENTS IN THE EXTRACTION OF TEETH. 

Some of the accidents attendant or consequent on 
the extraction of teeth, are of a grave character. 
Permanent deformity has sometimes been occasioned 
by extensive laceration of the soft parts, or by frac- 
ture of the alveolus and of the maxilla. Intense 
and protracted suffering frequently, and death some- 
times, follows such accidents. 



HEMORRHAGE. 

Excessive and obstinate hemorrhage in some cases 
follows the extraction of teeth, occasionally resulting 
seriously, and even fatally. There is in some consti- 
tutions a hemorrhagic diathesis, such as that from a 
small wound, or even a scratch, there will ensue per- 
sistent bleeding. This condition is dependent, first, 
on a lack of tone in the bloodvessels, so that they 
fail to contract at an injured or ruptured point ; and 
secondly, on a peculiar condition of the blood, such 
as to form coagulum with difficulty, as, when there 
is a relative deficiency of red corpuscles. It is one of 
the most important duties that ever devolve on the 
dentist, to make a correct diagnosis in cases where 
there is a tendency to hemorrhage. Close attention 
to the following points, will assist much in arriving 
at a just conclusion. In persons of a hemorrhagic 
tendency, there is a lymphatic, serous temperament ; 
a lack of tone in the soft parts — a soft, flabby condi- 



HEMORRHAGE. 349 

tion ; the skin pale, and devoid of the bright, vital 
appearance ; the eyes and hair of light color ; and the 
flow of saliva and mucus abundant. Besides these 
indications, much may be learned sometimes by pro- 
perly directed inquiries of the patient in regard to a 
disposition to hemorrhage on being wounded, either 
in his own case, or in that of his relatives ; if in the 
former, under what circumstances ; whether from an 
extensive or a slight wound ; from large or small 
vessels — from arteries or veins ; or, whether it oc- 
curred immediately, or after the lapse of some time. 
If the patient has never met with an accident suffi- 
cient to occasion excessive hemorrhage, and any of 
his relatives have, and a tendency to bleeding is sus- 
pected in the case, the operator should ascertain 
whether there is a similarity of temperament and 
constitutional tendencies between the patient and 
such relative. 

There are certain circumstances in which excessive 
hemorrhage would be more likely to occur than in 
others ; as, for instance, when there is an accidental 
relaxation, or lack of tone, in the system, especially 
the vascular system ; and also, when there is a sup- 
pression of any periodical discharges. There may be 
excessive hemorrhage from a ruptured vessel when 
there is no constitutional hemorrhagic tendency. 
There is sometimes a local difficulty with the vessels 
— a lack of tone in the part — on account of which 



350 ACCIDENTS IN TIIE EXTRACTION OF TEETH. 

obstinate hemorrhage will occur. A peculiarity of 
this kind is not very readily recognized. 

Violent passion, and, indeed, any strong agitation 
of the mind, will aggravate hemorrhage. Improper 
medication, as well as highly stimulating food, will 
have the same tendency. Anything that will in- 
crease the circulation, or reduce the tone of the 
sels, or change the condition of the blood, will 
increase the liability to hemorrhage. Simple deter- 
mination of blood to a part, however, would not indi- 
cate such a liability. When there is a special 
hemorrhagic diathesis, the blood will How from all 
the wounded surface, will be thrown out from all the 
ruptured capillaries. The most difficult cases are 
those in which there is a defect both in the vi- 
and in the blood. Usually, in such cases, there is a 
lack of red corpuscles in the blood, from which came 
it does not normally coagulate. If the blood is in a 
good condition, it will coagulate in ruptured capil- 
laries, though they might be deficient in tone ; but in 
larger vessels, though coagula might be formed, it 
would not be retained. 



TREATMENT. 

In cases where there is manifest hemorrhagic dia- 
thesis, prior treatment is indicated, if the necessity oi^ 
extraction is not urgent ; and that treatment will be 



HEMORRHAGE — TREATMENT. 351 

determined by the peculiar condition of the case. If 
there is a lack of tone in the vessels — an inability to 
contract — then the treatment should be of a tonic 
character ; and, if the blood is in good condition, this 
is the only treatment necessary ; but, if in a vitiated 
state, other treatment will be demanded ; the object 
of which is to produce an increase of red corpuscles. 
It is always better to postpone the operation, if at all 
practicable, till such treatment can be had as will 
bring the system to the best possible condition. 

Of the several methods of arresting hemorrhage, 
the proper one in a given case will be determined by 
the circumstances. Styptics, or astringents, applied 
directly to the ruptured surface, will often be found 
to produce coagulation of the blood, and thus stop its 
flow, without anything else. This kind of remedy 
will be efficient in those cases in which the applica- 
tion will produce contraction of the bleeding vessels, 
as well as coagulation of the blood. Sometimes this 
class of agents will fail to accomplish the object; in 
which case, in addition to them, compression should 
be made upon the part. Indeed, in many cases, the 
compress will effect all that is desired, without any 
other application. 

There are several methods of applying the com- 
press ; but the one best adapted to any given case, 
will be determined by circumstances; such as the 
extent of the wound, the character of the hemor- 



352 ACCIDENTS IN THE EXTRACTION OF TEETH. 

rhage, the location of the injury, and the size of the 
mouth. 

A very common method of making compression in 
the socket from which a tooth has been drawn, is, to 
force into the cavity pledgets of cotton, or small 
strips of linen, tightly, till it is full. It is well to 
saturate these with a solution of tannin, or some 
astringent preparation, applying it, too, in connection 
with the compression. In some caws, a simple pack- 
ing of the cavity in this manner, is quite sufficient ; 
but, in others, it is necessary to retain the pledgets 
in the socket by means of further compression. This 
is effected by placing a roll of linen, or perhaps bet- 
ter, a properly formed piece of cork on the packing, 
and then closing the jaws tightly upon this, and, if 
need be, placing a bandage under the chin, and tying 
it firmly over the head. The length of time during 
which it will be necessary to keep the jaws thus 
together, will depend on the nature of the case — 
from one to six hours. After the hemorrhage has 
entirely ceased, the bandage is to be removed care- 
fully, and the patient instructed to hold the jaws 
together on the compress for a time, and then gradu- 
ally to open the mouth, and remove the cork with 
much caution. After this, the packing should re- 
main in the socket from one to three days, and then 
be removed very carefully, one piece at a time, lest 
the ruptured vessels be opened up and the hemor- 
rhage caused to recur. 



HEMORRHAGE. 353 

The object in applying a compress is to bring it to 
bear upon the aperture of the wounded vessel, and in 
this way to prevent the escape of blood, till coagulum 
is formed and the opening permanently closed. The 
operator should ascertain the precise point from 
which the blood flows, and form the compress so as 
to bear full upon it. If the flow is from all the 
wounded surface, then the compress must be made to 
conform exactly to that throughout. 

An other method of making the compression, is to 
force softened wax into the socket, so as to fit it per- 
fectly ; remove it and chill it in cold water ; and then 
introduce and make compression upon it in the man- 
ner already described, following, throughout, the 
general directions. An other, and probably better 
method, is, to form cones of wax cloth, as near the 
shape and size of the root removed from the socket 
as possible. This material is prepared by dipping 
thin linen into melted beeswax, withdrawing it and 
letting it cool, and then cutting off strips of from a 
fourth to a half an inch wide, and rolling them into 
the proper size and shape. Having softened this 
material by heat, and freed the socket of coagulum, 
introduce and press it firmly into place, making the 
compression on it as already directed. This makes 
a very efficient compress for many cases. 

Plaster of Paris is sometimes used on the principle 
of a compress. Having the plaster mixed of the 



354 ACCIDENTS IN THE EXTRACTION OF TEETH. 

proper consistence, and the cavity clear, fill com- 
pletely with it, let it set, and then make compression 
on it in the usual manner. 

The fang of the tooth is sometimes returned to the 
socket to serve as a compress. It possesses the 
advantage of having a perfect adaptation ; but there 
is a liability of reunion between it and the socket; 
though this can be obviated by removing all the 
periosteum from the root. This method of compres- 
sion may be made more thorough by immersing the 
root in melted wax, and then, before this becomes 
too hard, introducing it into its original position. 
This makes a very perfect and efficient compress. If 
the crown is still remaining, when the jaws are 
closed it will come in contact with the opposing 
teeth, and thus be kept firmly in place, without any- 
thing further. It may be removed carefully after 
from one to three days. In cases where there is 
hemorrhage from the entire wounded surface, there 
will be a considerable flow of blood from the margin 
of the gum, even after plugging up the socket, and 
making compression by either of the methods des- 
cribed. In such case, after the socket is plugged up 
as already described, a plate is so fashioned as to fit 
tightly over the gum, and draw its margin down 
closely upon the compress. This pressure on the 
bleeding edges of the gum, checks the flow of blood 
there. The plate must be held down by the means 



HEMORRHAGE. 355 

already described. It is sometimes difficult to obtain 
an accurate fit for the plate, so as entirely to prevent 
the blood from continuing to ooze out. In such 
cases, make the plate to conform as nearly as conve- 
nient to the part; then fill up its concavity with 
plaster of Paris, mixed to a proper consistence ; and 
then place the whole upon the part, till the plaster 
conforms exactly to it, and retain it there till the 
plaster sets. This is then used for the compress. 
Or the inside of the plate may be thickly coated with 
softened gutta percha, in stead of plaster, and pressed 
upon the part in the manner already described, and 
employed in the same way. 

It will often require considerable discrimination to 
determine the best method of obtaining compression. 
Very great difficulty is occasionally experienced when 
a portion of the process has been broken away, or the 
soft parts have been lacerated. 

Various preparations are used as hemostatics. 
These agents serve to check hemorrhage in two 
ways: first, by facilitating a coagulation of the blood; 
and secondly, by producing a contraction of the ori- 
fice of the ruptured vessels. It is proper in all cases 
to use styptics in connection with the compress. The 
following agents have been used as styptics : tannic 
acid, creosote, nitrate of silver, chlorid of zinc, sul- 
phate of zinc, oil of turpentine, muriate of iron. The 
methods of applying these different preparations are 



356 ACCIDENTS IN THE EXTRACTION OF TEETH. 

the same. The agent is simply to be retained in 
contact with the part till it has exerted its influence. 
A solution of tannin in alcohol with creosote, equal 
parts, makes a very powerful styptic. 

The actual cautery is sometimes used to arrest 
hemorrhage ; but the propriety of using it in C 
where there is a manifest hemorrhagic diathesi 
exceedingly doubtful. When the scar produced by 
the hot iron is sloughed off, the hemorrhage is liable 
to occur with increased vigor, indeed, is certain to do 
so in almost every case when there is a strong pre- 
disposition. Constitutional treatment may be em- 
ployed to anticipate hemorrhage ; and it should have 
in view an increase of the relative amount of red cor- 
puscles in the blood, and a diminution of the serous 
portion, and also the production of a normal tone of 
the system. Saline purgatives may be used with 
very decided advantage, followed with acetate of lead. 
in connection with opium; the effect of the lead being 
to increase the coagulability of the albumen and 
fibrin. Care should be exercised, however, in its ad- 
ministration. 

Excessive hemorrhage will sometimes occur from 
very slight wounds ; death has been known to ensue 
from simply scarifying the gums. Mr. C. desired 
the removal of the first superior molar. The gum 
was separated from the neck of the tooth with the 
lancet, in the usual manner, when he refused to have 



HEMORRHAGE. 357 

anything further done, and left the office, there being 
a slight discharge of blood from the gum. After a 
few hours, the hemorrhage increased so as to cause 
alarm to the friends. The patient was some eight 
miles from a dentist, and a physician of rather mode- 
rate skill was called to the case. He probably did as 
well as he knew how, but failed to arrest the hemor- 
rhage, and succeeded in convincing the friends that 
no one else could do any better. The flow of blood 
continued for from three to four days, proving well- 
nigh fatal, but at last abated, and the patient re- 
covered. In this case, a properly directed compress 
would have checked the bleeding in a few minutes. 

Another case : Mrs. T. had nine teeth removed. 
The operation was not followed immediately by un- 
usual hemorrhage ; but, within two or three hours, 
the flow of blood had increased to an alarming ex- 
tent, so as to run from the mouth in a continuous 
stream. The indications were that the patient would 
soon die. She had become very weak. On exami- 
nation, the blood was found issuing only from the 
socket of one root of an inferior molar. The mouth 
and socket being cleansed of blood and coagula, it 
was perceived that the hemorrhage was from a small 
artery at the bottom of the socket, spouting out in 
jets with the pulsations. The treatment consisted in 
rolling up pledgets of cotton very tightly, saturating 
them with creosote and tannin, and forcing them in 



358 ACCIDENTS IN THE EXTRACTION OF TEETH. 

on the bottom of the socket, so as to make compres- 
sion upon the bleeding vessel. The socket was then 
rilled up, compression made, and the head bandaged 
in the manner already described. Thus the hemor- 
rhage was immediately checked, and no recurrence 
ensued. The constitution of this patient was of a 
scorbutic diathesis. 

Excessive bleeding often does not occur till con- 
siderable time after an operation ; and it may come 
on without any exciting cause, or be induced by 
vigorous muscular exercise, or by any intense mental 
excitement. Everything of this kind should be 
avoided, where there is a predisposition to hemor- 
rhage, and everything invited, that would tend to 
maintain the equilibrium of the circulation and the 
utmost quiet. 

FRACTURE OF THE ALVEOLUS. 

The ordinary fracture of the alveolus is a matter 
of no considerable consequence, if it receives proper 
attention. This fracture occurs to a greater or less 
extent under the following circumstances : first, when 
there is great divergence of the fangs, so that the 
tooth cannot pass from its socket, unless one or more 
of the roots are broken off, or the alveolus fractured ; 
second, where the tooth is forced out of the socket at 
a very considerable angle with its axis ; third, where 



FRACTURE OF THE ALVEOLUS. 359 

the alveolus is very firmly attached to the roots, and 
is very thin toward the points of these. Usually, the 
fracture is of that part which forms the socket of the 
tooth removed ; and when this is the case, it is of 
but small moment. It sometimes, however, extends 
far beyond this, involving the alveolus of from one to 
four of the adjacent teeth, and causing very serious 
injury, even the loss of the teeth themselves. Ex- 
tensive fracture, however, is far less liable to occur 
now, than when less perfect instruments were em- 
ployed. When the key was in such general use, 
extensive fracture of the alveolus was frequent ; but 
with the forceps, it is comparatively rare. 

When an accident of this kind does occur, all of 
the detached portion, whether large or small, should 
be removed. A pair of bone nippers will answer for 
this purpose. If there is much attachment to the 
soft parts, it should be dissected off, and then re- 
moved. If such fractured portions are permitted to 
remain, inflammation, and oftentimes sloughing of the 
gums, will ensue ; and necrosis of the bone is also 
sometimes produced by detached bone remaining in 
contact with the living. 

Sometimes extensive fracture occurs, involving the 
adjacent bony structure. In the case of Mr. W., in 
an effort to remove the first superior molar, the outer 
wall of the alveolus was separated from the other 
teeth. The fracture extended almost to the zygo- 



360 ACCIDENTS IN THE EXTRACTION OF TEETH. 

matic process, and detached a portion of the floor of 
the antrum, as well as a part of its outer wall. After 
the removal of this detached portion, there was a 
considerable external depression, that very much 
marred the form and symmetry of the face. 

Fracture of the alveolus should always be guarded 
against as carefully as possible. It always makes an 
unfavorable impression on the mind of the patient, 
which in many cases no explanation can obliterate. 
Whenever the accident does occur, the disagreeable 
knowledge of it may, if practicable, remain a secret 
with the operator. 

LACERATION OF THE GUMS. 

The gums are often bruised and lacerated with the 
key in the extraction of teeth. But this accident 
seldom happens with the forceps ; indeed, never, un- 
less the gum is very firmly attached to the neck of 
the tooth, and has not been separated with the lan- 
cet. The gum will sometimes be lacerated by adher- 
ing to a piece of the process, while the tooth is drawn 
from its socket, with the process and gum attached. 
With the various hooks and punches, the gums, lips, 
and cheeks are sometimes wounded. Accidents of 
this kind are to be prevented by placing a finger of 
the left hand, or a guard made of a roll of linen, in 
front of the instrument. When any considerable 



BREAKING THE TEETH. 361 

portion of the gum is lacerated, the detached portion 
should be cut off. The worst consequences from 
laceration of the soft parts occur where there is a 
hemorrhagic diathesis. The most effectual means 
of preventing accidents of this kind is to separate the 
gum perfectly, and guard well the points of the 
instrument. 



BREAKING THE TEETH. 

This is an accident of no small consequence, and is 
liable frequently to occur in the use of imperfect, ill 
adapted instruments, or in the unskillful use of good 
ones. It is of very common occurrence when the key 
is employed for extracting, even in the hands of those 
who claim to be skilled in its use. And with forceps, 
too, of the primitive form, the teeth were so fre- 
quently broken, as almost to preclude their use as 
extracting instruments. This accident usually occa- 
sions great pain to the patient, as well as protracts 
the operation, and diminishes his confidence in the 
ability of the operator. One such accident will 
create more prejudice than fifty skillful operations 
can obliterate. 

In all cases where a tooth is broken, the root, if 
possible, should be removed ; for, if it be not, con- 
tinuous or periodical pain, inflammation, alveolar 
abscess, and the like affections, are liable to ensue. 



362 ACCIDENTS IN THE EXTRACTION OF TEETH. 

The remark is often made, when teeth are broken, 
that the gums will close over the roots and thus 
effectually protect them, and no disagreeable conse- 
quences will follow. In no ordinary case will the 
gums unite over even the smallest portion of root 
that may have been left in the socket. 

REMOVAL OF A WRONG TOOTH. 

There is very rarely any excuse for the removal of 
a sound, healthy tooth in the immediate vicinity of a 
diseased one, unless it be in a case of those deep- 
seated, hidden affections which are difficult to diag- 
nose. It sometimes happens, however, that a sound 
tooth is removed ; and when a mistake of this kind 
is made, the diseased tooth should also be at once 
removed, and then, if the conditions are favorable, 
the healthy one should be immediately replaced: 
The circumstances most favorable for such replace- 
ment, are, a good constitution in a state of health, 
and a normal condition of the mouth, especially of 
the gums and mucous membrane, so that the attach- 
ment would take place with as little inflammation 
and soreness as possible. If the tooth is necessarily 
kept out of the mouth many minutes, it should be 
placed in cold water; and before the replacement, 
the socket should be thoroughly cleansed of coagu- 
lum. The tooth is then introduced, pressed firmly 



DISLOCATION OF THE INFERIOR MAXILLA. 3G3 

to place, and allowed to remain without disturbance 
or irritation, till the attachment has become com- 
plete. During the time it is reuniting, treatment 
may be required to counteract inflammation. Meager 
diet, abstinence from stimulants, and quiet, should 
always be recommended in the case. 

This operation has been, wholly condemned by some 
very good dentists. Dr. Koecker declares that it 
should never be attempted. But numerous success- 
ful cases, w T ell attested, give assurance that it may 
very frequently be accomplished with the most satis- 
factory results. Mr. T., aged 15, of good constitu- 
tion, and in good health, and with the mouth princi- 
pally in a normal condition, had the second inferior 
bicuspid of the left side removed by mistake, the first 
molar being the offending tooth. The former was at 
once put into cold water, and the latter forthwith 
extracted. The socket of the bicuspid was then 
cleansed, and the tooth replaced. There was slight 
soreness for a few days, after which the tooth was 
found to have made a firm and permanent reattach- 
ment ; and from that time to this — sixteen years — it 
has remained perfect, and is now as healthy, lifelike, 
and valuable as any other tooth in the mouth. 

DISLOCATION OF THE INFERIOR MAXILLA. 

The dislocation of the inferior maxilla is an acci- 



364 ACCIDENTS IX THE EXTRACTION OF TEETH. 

dent of not very frequent occurrence. In persons of 
lax muscles and with large mouths, the operation of 
extracting teeth is liable to produce it ; sometimes 
when the operation is on the upper jaw, but more 
frequently when it is on the lower. In the former 
case, it is an effect of the patient's effort to open the 
mouth; but in the latter, generally that of the move- 
ment of the jaw by the instrument. The dislocation 
consists in a downward and forward movement of 
one or both of the condyles, so that they are' thrown 
out of their sockets, and rest in front of the anterior 
rim. In such case, the mouth is distended to its 
utmost, the chin thrown, down on the breast, and 
deglutition and speech rendered impossible. Some- 
times but one condyle will be thrown out ; in which 
case the jaw is thrown downward and to one side. 

•This accident seldom or never occurs with patients 
who have small months or firm muscles. When it 
does happen, however, the dislocation should be 
promptly reduced. Of the various methods of accom- 
plishing this reduction, the one most commonly em- 
ployed, which is very efficient, is as follows : if both 
condyles are dislocated, place corks, or some similar 
substance, between the superior and the inferior molar 
teeth of both sides ; and then, with the fingers of 
both hands, make firm, steady pressure on the chin 
upward and backward, thus shoving the condyles 
downward and backward into their proper places. 



SYNCOPE. 365 

If but one condyle is out, the cork should be applied 
only on that side, and in the same manner already 
directed. An other method is, to substitute the 
thumbs of the operator for the corks, placing them 
in the same position between the teeth, and manipu- 
lating with the fingers on the chin, as before. The 
patient should be placed in a recumbent position for 
the operation. An other method is, to make down- 
ward and backward pressure on the coronoid process, 
and in this manner cause the condyles to glide into 
their places. This accomplishes the reduction with- 
out taking hold of the jaws, or placing a fulcrum 
between them. 

This accident is far more liable to occur the second 
time in the same case. In extracting the lower molar 
teeth for one who has suffered a dislocation, or is pre- 
disposed to it, the lower jaw should be very firmly 
supported with the left hand ; or, the accident may 
be prevented by placing a bandage under the chin, 
and over the head, so that the mouth can not be 
opened to its furthest extent ; and this is the surest 
method. In all cases after an accident of this kind, 
the patient should abstain from solid food for a few 
days, or at least till the soreness is abated, and avoid 
everything promotive of inflammation. 

SYNCOPE. 

Syncope, or fainting, is frequently brought on by 



366 ACCIDENTS IN THE EXTRACTION OF TEETH. 

extraction of the teeth, and even by other operations 
upon them ; indeed, it is sometimes produced simply 
by cutting the gums, or by the sight of blood, or, in 
some instances, by dread of the operation. It con- 
sists in an intermission of the heart's action, and 
consequently irregularity of the circulation of the 
blood, accompanied with a temporary suspension of 
the functions of the brain and a loss of conscious] 
Difficult or suspended respiration, lividness of the 
skin, and inability to move. are the external indica- 
tions of the condition. There are no constitutional 
appearances known, by which a predisposition to 
syncope can be determined: persons of all apparent 
conditions and peculiarities are subject to it. The 
most strong, robust, and healthy sometimes faint 
under the most trivial influences; while others, of 
the weakest and feeblest constitutions, can not be 
brought into this condition by any ordinary means; 
so that nothing can be predicated of appearanc 
to such predisposition. The fainting may occur once 
or twice in the same case, even under the most sim- 
ple operation, owing to some temporary condition of 
the system, and never happen again under any cir- 
cumstances whatever. 

It sometimes comes on before, sometimes after, and 
sometimes during, the operation. There is greater 
liability to it after a recent meal than after digestion 
is completed, since the nervous energy, during dig 



SYNCOPE. 367 

tion, is directed to the stomach and its appendages, 
and thus the circulating apparatus has less of nervous 
force. 

The frequent occurrence of syncope indicates a 
constitutional predisposition to it, and may enable 
the operator to anticipate it to some extent, by the 
aid of stimulants, such as brandy, or, what is in 
some respects preferable, a galvanic current. The 
patient subject to such affection, should be placed, 
for an operation, as nearly as practicable in a recum- 
bent position — especially for the extraction of teeth 
— and his mind kept as tranquil as possible. 

To restore the patient from syncope, place him in 
a horizontal position, the head quite as low as the 
body, and apply volatile stimulants to the nostrils, 
and dash water on the face and chest. All compres- 
sion should be removed from the body, especially 
from the chest, as it would constrain the action of 
the respiratory muscles. This remark is peculiarly 
applicable to female patients. This treatment will 
usually be quite sufficient to effect a rapid reaction 
and resuscitation. 



CHAPTER XIII. 

ANESTHETICS. 
ETIIER — CHLOROFORM. 

Sulphuric ether was the first agent successfully 

employed for producing insensibility to pain during 
surgical operations. It was brought to the notice of 
the profession in 184G by Dr. W. G. L. Morton. The 
mode of administering it is. by inhalation of the 
vapor; and it produces its effects in a short time, 
depending on the quality of the ether, the amount of 
air introduced with it, and the susceptibility of the 
patient. A complicated instrument, denominated an 
inhaler, was first employed for its administration; but 
it soon became apparent that this was not at all ne- 
cessary, and that simpler methods were preferable, 
because more easily regulated and adapted to circum- 
stances. The best method is, to inhale it from a 
sponge or napkin, since, in this way, the admission 
of the air can be controlled entirely by the will of the 
operator, graduating it to the requirements of the 
case. 



ETHER — CHLOROFORM. 369 

During the administration, the patient should be in 
a reclining posture ; though it is held, by much good 
authority, that a horizontal position is the safest, 
because, in that, the force of the circulation is most 
nearly equalized. In the administration of general 
anesthetics, the circulation is always more or less 
affected. It is an opinion very generally received, 
and probably correct, that, where there is functional 
derangement of the heart, lungs, or brain, general 
anesthesia should not be employed. This opinion, 
however, is perhaps derived more from analogy than 
from actual observation. It is true that, other things 
being equal, the liability to injury in such case would 
be greater; but the danger with both ether and chlo- 
roform is, that there are cases in which there is an 
undefinable and undetectable idiosyncracy, or malsus- 
ceptibility of its influence, to a great extent indepen- 
dent of pathological conditions. 

The patient having been placed in a comfortable 
position, and his mind freed as far as possible from 
apprehension, he should be directed to breathe tran- 
quilly by full inspirations, carefully guarding against 
any compression of the chest, so as to allow the re- 
spiratory muscles free play. During the administra- 
tion of the anesthetic, a strict watch must be main- 
tained over the patient, having reference to the fol- 
lowing points : the breathing should be free and easy, 
without irritation of the throat or bronchia ; the skin 



370 ANESTHETICS. 

should not become blanched, but should retain a 
florid,' lively color ; but the great criterion is the 
pulse, and the indications given here should be strictly 
observed and obeyed. In order that the operator 
may follow every indication, he should be familiar 
with the manifestations of the pulse in different con- 
stitutions, and under different circumstances. During 
the administration of ether or chloroform, the pulse 
usually becomes more frequent ; but it should not be 
much accelerated, nor its strength and fulness be 
much diminished. Enfeebled or irregular pulse should 
in all cases be regarded as a warning: and if the 
feebleness and irregularity be very marked, the ope- 
rator should desist. In some instances, death has 
occurred after a few inhalations ; but perhaps only in 
the use of chloroform. This fact intimates that the Brat 
effectsof the administration should be very closely noted. 
The degree to which the anesthesia should be car- 
ried, is a matter about which there is much diversity 
of opinion. Every condition of it, from that of simple 
allayed irritability to that of complete insensibility 
and unconsciousness, has its advocates. But the 
extent to which the administration may be carried, 
will be suggested by the indications already referred 
to, and, if these are unfavorable, should be determined 
at once. Mere nausea, however, without any other 
unfavorable symptom, is not a counter-indication in 
the use of ether or chloroform. 



ETHER — CHLOROFORM. 371 

The method of administering chloroform is the same 
as that for ether, except that, in the use of the former, 
more care and closer observation are required. Chlo- 
roform is more rapid and powerful in its action than 
ether, and hence more liable to do injury; but, inde- 
pendently of this fact, it is generally believed that the 
former is less safe than the latter, when taken into 
the system, especially by inhalation. A mixture of 
ether and chloroform, or chloric ether — usually equal 
parts of chloroform and ether, but the proportions are 
sometimes varied — is used by some ; the object being 
to secure greater promptness than with ether alone, 
and incur less danger than with chloroform ; and it 
is probable that a mutual compensation in these re- 
spects is thus to be attained. 

If either chloroform or ether has been administered 
to entire unconsciousness, the patient should be per- 
mitted to pass out of the condition spontaneously; 
for, after such a revival, there will be less liability to 
unpleasant feelings, as headache, depression, and 
nausea. The fingers of the person administering the 
chloroform should be kept on the carotid, since the 
state of the circulation will be better recognized by 
this than by the radial artery, and it is a more con- 
venient point for observation. In favorable cases, it 
is preferable to continue the inhalation till there is a 
muscular relaxation. 

When a condition arises in which respiration is 



372 ANESTHETICS. 

suspended, and the circulation partially or altogether 
stopped — a condition of imminent peril — active mea- 
sures must be resorted to for the patient's restoration. 
Efforts must be directed to a recovery of the circula- 
tion, by friction, motion, etc.; but to restore the 
respiration, is the first, immediate, imperative consi- 
deration. Any or all of the ordinary methods of re- 
establishing suspended respiration may be employed. 
Cold water should be dashed in the face, and on the 
throat and chest, and volatile stimulants applied to 
the nostrils; the glottis should be titillated with a 
feather, or some such implement, to excite it to action; 
and artificial respiration, by some approved method, 
should be at once adopted. The galvanic current, 
too, may be brought into requisition, to excite the 
respiratory muscles to action, and to act also upon the 
circulation. In all cases of accident of this kind, 
prompt and efficient measures should be immediately 
taken ; for a delay of a few moments may be attended 
with fatal results. 

LOCAL ANESTHESIA. 

Because of the frequently prejudicial and sometimes 
fatal consequences to which systemic anesthesia is 
liable, local anesthesia has been much brought into 
requisition ; among the agencies for producing which 
may be first reckoned 



LOCAL ANESTHETICS. 373 

Congelation. — Of the various freezing mixtures and 
implements applicable for this purpose, the apparatus 
chiefly used, and perhaps the best yet brought to the 
notice of the profession, consists of two parts of pul- 
verized ice and one of salt, applied by means of an 
instrument of the following description : a vulcanized 
India-rubber tube, about five inches long and one inch 
in diameter, closed at its superior extremity by a 
screwcap, and open at its inferior, which latter is 
slightly enlarged and cut out, so as to leave two lips 
to reach down on the sides of the tooth ; within the 
tube, a follower and a spiral spring, the latter forcing 
the former down to the open end. When this instru- 
ment is to be used, tie a piece of oiled silk or mem- 
brane loosely over its inferior end, fill it expeditiously 
twothirds full with the ice and salt, prepared as 
above, adjust the follower and spring in place, screw 
on the cap, and apply at once. The sac of the in- 
strument is to be pressed and worked gradually down 
till it invests a portion of the gum on each side of the 
tooth to be extracted. As the ice melts in the sac, 
the follower forces the unmelted portion down next to 
the tooth and gum. The application should be con- 
tinued from one to three minutes, or till the margin 
of the gum is congealed — as will be indicated by its 
hardness and whitened appearance — and then the 
tooth should be extracted as expeditiously as possible, 
though with all the ordinary skill and care. 



374 ANESTHETICS. 

If the contiguous teeth are sound, and not to be 
extracted, they must be protected as far as possible 
from the influence of the application — as they may 
be, by having their crowns enveloped in thin sheets 
of wax, oiled silk, or any otjier substance that is a 
nonconductor, and is not too bulky. Where some 
such protection is not afforded, great injury is liable 
to ensue. 

If the tooth to be extracted is sensitive, the tem- 
perature should be reduced by holding in the mouth 
cold water, and finally a piece of ice ; and immediately 
after, the instrument should be applied. When the 
pulp of the tooth is exposed, the application would be 
intolerable. In such case, it has been recommended 
first to apply arsenic for twenty four hours to the ex- 
posed pulp. This method of procedure, however, will 
be found wholly impracticable. 

Under the full influence of the freezing mixture, the 
circulation in the part is wholly arrested, and the 
sensibility entirely obtunded, so that the operation, 
properly performed, produces no pain. In the extrac- 
tion, the gum, so far as congealed, may, if necessary, 
be embraced by the forceps and broken away without 
pain. After the operation, cold water or ice should be 
applied to the part, to prevent a too rapid reaction, 
which would be very painful, but which, thus gra- 
duated, occasions but slight pain, and in some a 
none at all. 



EXTRACTION BY ELECTRO-MAGNETISM. 375 

The aim in all cases should be to produce congela- 
tion to the very point of the root ; for, without this, 
the extraction will cause pain. And it is far more 
difficult to effect this object where only the root, than 
where the crown is remaining ; for this serves as a 
conductor. In the former case, however, a screw or 
iron wire may be introduced into the root, and left 
projecting, to serve as a conductor. But in some 
cases, especially in those of roots, it is improper to 
attempt the employment of congelation at all. The 
practicability of a desirable result will depend much 
upon the skill and tact of the operator, and the sus- 
ceptibility of the parts. In patients of full habit and 
active circulation, it is very difficult to produce insen- 
sibility by congelation ; and in such cases great pain 
usually attends its application. 

EXTRACTION BY ELECTRO-MAGNETISM. 

The employment of electro-magnetism in the ex- 
traction of teeth is of recent date, it being only about 
a year since its general introduction to the dental pro- 
fession. In this time, however, it has been exten- 
sively used. There is a great diversity of opinion as 
to its efficiency for relieving pain ; for, while some 
have been disposed to assume that, when properly 
employed, it would, in the generality of cases, miti- 
gate .pain, and, in the majority, obviate it altogether, 
others, after having thoroughly tested it, as they 



376 ANESTHETICS. 

affirm, maintain that it does not produce insensibility 
to any appreciable extent, and consequently does not 
relieve the pain, but that, at most, it only complicates 
the sensations, the pain of the tooth-drawing becom- 
ing involved in the confusion of other feelings, so that 
the patient can hardly decide whether he has been 
definitely hurt or not ! 

In using this agent for the process of extracting 
teeth, the susceptibility of the patient to its. influence 
must be carefully regarded. Some persons an 
peculiarly constituted that an electric current is al- 
most intolerable to them ; while others will i 
strong current with pleasurable sensations. To the 
former, the electricity would 1 inful as the 

traction of the tooth; but to the latter, when properly 
applied, it mitigates, and in many cases altogether 
obviates, the pain. The reason of this difference in 
its action is not very clearly understood. Several 
theories in regard to it have been advanced, but none 
of them sufficiently plausible to challenge conviction. 

Again, the manner in which, and the condition of 
the parts to which, this agency is applied, are to be 
closely observed. Where there is acute periostitis, 
an electric current, even though feeble, would produce 
intense pain, and should not be applied ; though, in 
such cases, it has been suggested that an application 
of the charged sponge to the gums will produce insen- 
sibility. 



APPLICATION. 377 



APPLICATION. 



The method of application is very simple. Any 
ordinary battery, of convenient form, may be em- 
ployed for this purpose. It should be uniform in its 
action, and the vibration as short as possible. The 
common zinc-and-copper battery, with the sulphate- 
of-iron solution, is perhaps the most convenient and 
safe. One pole of the battery — no matter which — is 
attached to the forceps, and the other to a handle of 
size and form convenient for the patient to grasp. To 
ascertain his susceptibility, the current should always 
first be tested on the patient, by placing the handle 
and the forceps one in each of his hands, and letting 
it on first feebly, and then gradually increasing it till 
he experiences the sensation just beyond the elbows; 
when, finally, it is to be slightly weakened. The 
gum having been separated, the forceps, with its ap- 
pendages, is adjusted to the tooth, the connection 
made by placing the handle in the patient's hand, and 
the tooth at that moment removed. It has been re- 
commended by some to place the forceps on the tooth, 
and complete the circuit, as above, with the current 
very feeble, and then gradually increase it to the 
proper force for the operation. In some cases, per- 
haps, this would be the preferable mode. 

An other method of producing insensibility by an 



378 ANESTHETICS. 

electric current is, to place two moistened sponges, 
connected with the two poles of the battery, on the 
gum, one on each side of the tooth, keep them there 
a few moments, and then operate. This method, 
however, has not yet been sufficiently tested to ascer- 
tain its merits. 



INDEX. 



Atrophy, 29. 

cause of, 30. 
Amalgam, 88. 
Adhesive foil, 154. 
Actual cautery, 236. 
Arsenious acid, 218. 

application of, 239. 
Alveolar abscess, 259. 

treatment of, 2G1. 
Attachment of an artificial crown, 275. 
Accidents in the extraction of teeth, 347. 
Anesthetics, 368. 
Application of electro-magnetism, 377. 

Broaches, 101. 
Bur drill, 96. 
Block filling, 148. 
Breaking of the teeth, 361. 

Chloroform, 368. 
Chemical abrasion, 36. 

cause of, 37. 
Comparative liability of the teeth to decay, 62. 



380 iNbEX. 

Caries of the teeth, 41. 

causes of, 51. 

exciting causes of, 55. 

consequences of, 63. 

treatment of, 66. 
Crystal gold, 86, 158, 177. 
Classification of decayed cavities, 166. 
Creosote or carbolic acid, 214. 
Chloride of zinc, 216. 



Deposits, 18. 

points of, 20. 
Denuding, 34. 
Drills, 96. 
Drill stocks, 100. 
Drying cavities, 139. 
Destruction of the pulp, 231. 
Dislocation of the inferior niaxillar, 363. 

Ether, 368. 

Extraction preparatory to the insertion of artificial dentures. 'MO. 

Exostosis, 31. 

effects of, 33. 

cause of, 33. 
Examination of decays. 125. 
Excavators, 101. 

manufacture of, 105. 
Exposed pulps, 221. 

treatment of, '-'Jr.. 

destruction of, 231. 
Extraction of teeth, 285, 319. 
Extracting instruments, 294. 
Elevators, 311. 
Extraction by electro-magnetism. 315. 






INDEX. 381 

Extraction of the inferior incisors, 331. 

Filling teeth, 124. 

examination of, 125. 

opening cavities, 126. 

drying cavities, 139. 

removal of decay, 128. 
Forming cavities, 131. 
Forming blocks, 149. 
Finishing fillings, 162. 
Filling by classes and modifications, 168. 
Filling with foil, 173. 

Filling large cavities on the labial surfaces of superior incisors, 201. 
Filling pulp-cavities and canals, 244. 
Filling the crown, 272. 
Forceps, 299. 
Fracture of the alveolus, 358. 

Green tartar, 24. 

treatment of, 26. 
General remarks on filling, 71. 
Gold, 83. 

General remarks on extraction, 285. 
Gum lancet, 315. 

Hemorrhage, 348. 

Heavy cutting-instruments, 74. 

Inferior molars, extraction of, 335. 
Inferior dens sapientiae, extraction of, 339. 
Inferior bicuspids, extraction of, 334. 
Introduction, 17. 
Irregularity of the teeth, 27. 

effects of, 28. 
Instruments for filling, 94. 
Introducing the filling, 142. 
Introducing the blocks, 151. 



382 INDEX. 

Indications for extraction, 292. 
Inferior 'cuspids, extraction of, 332. 

Lead for filling, 79. 
Laceration of the gums, 360. 
Local anesthesia, 372. 

Materials for filling, 7.3. 

metallic, 75. 

non-metallic, 91. 
Manufacture of excavators, 105. 
Mode of using the file, 114. 
Metallic pivots, 2 

Necrosis of the teeth, 38. 

causes of, 39. 
Nitrate of silver, 214. 

Opening cavities, 12G. 

Platinum, 82. 

Plugging instruments, 106. 

Pathological conditions, 206. 

Potential cautery. 

Preparing the teeth for filling, 251. 

Pivot teeth. I 

Pellets for filling, 154. 

Removal of the dens sapientia?, 
Removal of decay, I . 
Removal of a wrong tooth, 302. 

Silver. 

Separation of the teeth, US. 

Special cases. 199. 

Superior cuspids, extraction of. 321. 

Superior bicuspids, extraction of, 323. 

Syncope, 365. 



INDEX. 383 

Tartar, 18. 

origin of, 19. 

effects of, 21. 

method of removing, 22. 
Tin, 80. 
The file, 111. 

use of, 113. 
The palatal portion of the crown broken away, leaving the outer portion 

standing — nerve not exposed, 200. 
Treatment of inflamed dentine, 210. 
Tannin or Tannic Acid, 213. 
Terchloride of gold, 217. 
The key, 295. 

The method of lancing the gnms, 317. 
Treatment of hemorrhage, 350. 

Various preparations of gold, 85. 












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